Risk Factors for Postpartum Hemorrhage in Current Pregnancy
A history of previous PPH is the strongest risk factor placing this patient at high risk for recurrent PPH, with a 3.5 to 9-fold increased risk compared to women without this history. 1, 2
Primary Risk Factor: Previous PPH History
Previous postpartum hemorrhage is the most significant predictor of recurrent PPH in the current pregnancy. The evidence demonstrates:
- Women with prior PPH have a 3.5-fold increased risk of PPH in subsequent deliveries (19.1% vs. 5.4% in unaffected women) 1
- History of severe PPH carries an adjusted odds ratio of 8.97 (95% CI: 5.25-15.33), making it the strongest independent risk factor 2
- Previous PPH is consistently identified as one of the greatest risk factors for recurrent hemorrhage 3
Specific High-Risk Features from Previous PPH
The risk is particularly elevated if the previous PPH involved:
- Blood transfusion at the index delivery 1
- Manual removal of placenta at the index delivery 1
- These complications indicate more severe hemorrhage and predict higher recurrence risk 1
Secondary Risk Factor: Advanced Maternal Age
Advanced maternal age is a documented but weaker risk factor compared to previous PPH history:
- Older maternal age is significantly associated with severe PPH 4
- However, the specific age threshold and magnitude of risk are not as clearly defined as the previous PPH risk 4
- This factor contributes to overall risk but is substantially less predictive than previous PPH history 4, 2
Additional Risk Factors Present
While not listed in the question options, this patient has other relevant considerations:
- Singleton pregnancy at 50th percentile: This is actually protective compared to multiple pregnancy, which carries an adjusted OR of 2.11 for severe PPH 2
- The normal fetal size reduces risk compared to macrosomia 4
Clinical Implications for Current Pregnancy
This patient requires high-risk obstetric management based primarily on her previous PPH history. 1, 3
Modifiable Risk Factors to Address
- Labor induction increases recurrence risk (OR 1.5; 95% CI 1.2-1.9) and should be avoided unless medically indicated 1
- Planned cesarean section reduces recurrence risk (OR 0.6; 95% CI 0.4-0.7) compared to planned vaginal delivery 1
- Personalized counseling based on the specific circumstances of her previous PPH is essential 1
Preventive Measures Required
- Blood type and screen before delivery 5
- Active management of third stage with oxytocin 5, 6
- Tranexamic acid 1 g IV should be immediately available for administration within 3 hours if bleeding occurs 7
- Uterotonic medications readily available in delivery room 3
- Close surveillance in immediate postpartum period (at least 24 hours) 7
Common Pitfall to Avoid
Do not assume that advanced maternal age alone places this patient at high risk. While it contributes to overall risk, the previous PPH history is the dominant and most clinically significant risk factor requiring intensive monitoring and preventive strategies 1, 2. The combination of both factors warrants comprehensive preparation, but the previous hemorrhage history drives clinical decision-making 1, 3.