Secondary postpartum hemorrhage: Incidence, etiologies, and clinical courses in the setting of a high cesarean delivery rate.

PONE-D-21-34785

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Reviewer #2: Yes

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Reviewer #1: Dear Respectable Editor

Thank you to give me the opportunity to review thw manuscript entitled (Secondary postpartum hemorrhage: Incidence, etiologies, and clinical courses in the setting of a high cesarean delivery rate).

Which designed to evaluate the incidence, etiologies, and clinical outcomes of secondary postpartum hemorrhage in a hospital with a high cesarean section rate and to compare the etiologies of secondary postpartum hemorrhage following cesarean delivery versus vaginal delivery.

This retrospective study included 123 women with secondary postpartum hemorrhage who were treated at a tertiary-level hospital.

The study found that the incidence of secondary postpartum hemorrhage was 0.21%. The median onset of bleeding was 12 days after delivery. Fifty-two percent of the deliveries were by cesarean section. The most common etiology of secondary postpartum hemorrhage was endometritis (67.5%), followed by retained placental tissue (21.1%). Women who delivered by cesarean section had a higher rate of endometritis (80.0% vs 53.4%) and a lower rate of retained placental tissue (10.8% vs. 32.8%) than those who delivered vaginally. Surgical intervention included uterine evacuation in 29.3% and hysterectomy in 8.1% of the patients. Five percent of women were treated by embolization.

The study concluded that women who delivered by cesarean section were less likely to have retained placental tissue but were at higher risk for endometritis and uterine pseudoaneurysm than those who delivered vaginally.

The authors provide a structured abstract and informative title

The methodology and the results are clear.

In the discussion they compared their findings, with other authors findings and they mentioned the strength and limitations of their study.

They reached clear conclusions and relevant references.

Finally, I have no suggestions and I think the manuscript discuss an interesting subject to the readers and can be accepted for publication.

Regards

Reviewer #2: The results well represent what is expected from a center with a high cesarean section rate of 52%. The incidence of retained placenta would be low for cesarean delivery when compared to vaginal delivery and also endometritis would be one the highest etiology for secondary postpartum hemorrhage when compared to retained products

Thank you.

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Reviewer #1: Yes: Ibrahim A. Abdelazim (Professor of Obstetrics and Gynecology, Ain Shams University)

Reviewer #2: No