Immediate postpartum hemorrhage with referral from local clinics: More than 10-year experience at mackay memorial hospital, Taipei, Taiwan

OBJECTIVE: To investigate the etiologies, management, and outcomes of postpartum hemorrhage (PPH) cases referred from local clinic, and to analyze the potential causes of poor prognosis and find out possible preventive measure. MATERIALS AND METHODS: This is a retrospective cohort study conducted at a tertiary referral center in Taipei, Taiwan, from January 2011 to February 2025. Medical records of primary PPH cases referred from local clinics were reviewed, excluding cases of amniotic fluid embolism and secondary PPH. A total of 159 patients were categorized into eight etiologic groups: birth canal laceration, uterine rupture, vessel injury during cesarean section, placenta accreta spectrum, placenta previa, uterine inversion, uterine atony, and retained placental tissue. Clinical characteristics, management approaches, and outcomes were analyzed. RESULTS: Among the 159 enrolled cases, birth canal laceration was the most common cause (59.1%) with 27.7% of cases admitted to ICU. The overall hysterectomy rate was 4.4%, and the mortality rate was 1.3%. Intrauterine laceration, placenta accreta spectrum, and vascular injury during cesarean section showed the highest rates of receiving exploratory laparotomy and hysterectomy. Four patients experienced out-of-hospital cardiac arrest (OHCA); two died despite having ACLS and hysterectomy, and one survivor developed hypoxic-ischemic encephalopathy. CONCLUSION: PPH remains a major cause of maternal morbidity and mortality. Birth canal laceration was the most frequent cause of referred PPH, whereas placenta previa, placenta accrete spectrum, and uterine rupture were strongly associated with poor maternal outcomes. OHCA with 50% mortality rate, highlights the crucial need of preventing maternal cardiac arrest before arrival at referral centers. For placenta previa or accreta spectrum, planned transfer before delivery is preferable than emergency transfer. Early recognition, timely fluid resuscitation or blood transfusion, slow down bleeding speed, and rapid referral are essential. Therefore, regular training in immediate PPH management and referral protocols may shorten transfer delays and reduce adverse outcomes.