What is the most likely risk factor for postpartum hemorrhage (PPH) in a 23-week pregnant gravida 3, para 2 (G3P2) woman with a history of PPH in a previous pregnancy?

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Most Likely Risk Factor for Postpartum Hemorrhage in This Patient

Previous postpartum hemorrhage is the most significant risk factor for this patient (Option A), conferring a 3.5-fold increased risk of recurrent PPH compared to unaffected women. 1

Evidence Supporting Previous PPH as the Primary Risk Factor

Previous PPH represents one of the greatest risk factors for recurrent hemorrhage in subsequent pregnancies. 2 The data demonstrates that women with a history of PPH have a recurrence rate of 19.1% compared to only 5.4% in women without prior PPH (OR 4.1; 95% CI 3.7-4.5). 1

Why Other Options Are Less Significant

Multiparity (Option C)

  • Multiparity itself is only a weakly associated factor with PPH. 3
  • While primiparity is actually listed as a major independent risk factor for PPH 4, this patient is G3P2, making her multiparous rather than primiparous
  • The evidence does not support multiparity as a strong independent risk factor when compared to previous PPH 3

Multiple Pregnancy (Option B)

  • Multiple pregnancy is indeed a recognized risk factor for PPH 5, 3
  • However, there is no indication in this clinical scenario that the patient has a multiple pregnancy at 23 weeks
  • The question states "exam normal" with no mention of twins or higher-order multiples
  • This option would only be relevant if the patient actually had a multiple gestation, which is not stated

Clinical Implications for Management

The 3.5-fold increased risk of recurrent PPH necessitates specific preventive strategies: 1

  • Identification of this high-risk patient through complete history taking 2
  • Vigilant management of the third stage of labor 2
  • Having uterotonic medications readily available in the delivery room 2
  • Consideration of the specific circumstances of the previous PPH (whether it involved blood transfusion or manual removal of placenta, as these further increase recurrence risk) 1

Important Caveats

The risk of recurrent PPH is further modified by delivery management decisions: 1

  • Labor induction in the subsequent pregnancy increases recurrence risk (OR 1.5; 95% CI 1.2-1.9) 1
  • Planned cesarean section reduces the risk compared to planned vaginal delivery (OR 0.6; 95% CI 0.4-0.7) 1

Personalized counseling based on the previous PPH characteristics, relevant labor history, and maternal preferences should guide delivery planning. 1

References

3
Research

Postpartum haemorrhage.

Current opinion in obstetrics & gynecology, 1995

4
Research

Risk factors for postpartum hemorrhage: can we explain the recent temporal increase?

Journal of obstetrics and gynaecology Canada : JOGC = Journal d'obstetrique et gynecologie du Canada : JOGC, 2011

5
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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