Objective
The purpose of this study was to compare 4 national guidelines for the prevention and management of postpartum hemorrhage (PPH).
Study Design
We performed a descriptive analysis of guidelines from the American College of Obstetrician and Gynecologists practice bulletin, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, the Royal College of Obstetrician and Gynaecologists (RCOG), and the Society of Obstetricians and Gynaecologists of Canada on PPH to determine differences, if any, with regard to definitions, risk factors, prevention, treatment, and resuscitation.
Results
PPH was defined differently in all 4 guidelines. Risk factors that were emphasized in the guidelines conferred a high risk of catastrophic bleeding (eg, previous cesarean delivery and placenta previa). All organizations, except the American College of Obstetrician and Gynecologists, recommended active management of the third stage of labor for primary prevention of PPH in all vaginal deliveries. Oxytocin was recommended universally as the medication of choice for PPH prevention in vaginal deliveries. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists and RCOG recommended development of a massive transfusion protocol to manage PPH resuscitation. Recommendations for nonsurgical treatment strategies such as uterine packing and balloon tamponade varied across all guidelines. All organizations recommended transfer to a tertiary care facility for suspicion of abnormal placentation. Specific indications for hysterectomy were not available in any guideline, with RCOG recommending hysterectomy “sooner rather than later” with the assistance of a second consultant.
Conclusion
Substantial variation exists in PPH prevention and management guidelines among 4 national organizations that highlights the need for better evidence and more consistent synthesis of the available evidence with regard to a leading cause of maternal death.
Postpartum hemorrhage (PPH) is the most common cause of maternal death and is responsible for one-quarter of maternal deaths globally, totaling approximately 140,000 deaths annually. Although PPH is common, with an incidence of 5-15% of births, life-threatening bleeding, defined by the Royal College of Obstetrician and Gynaecologists (RCOG) as an estimated blood loss >2.5 L or receipt of >5 units of blood products or treatment for coagulopathy, which is estimated to occur in 3.7 per 1000 pregnancies.
An important component of patient safety and the reduction of adverse outcomes includes the development of unambiguous guidelines. Previous comparisons of national guidelines on topics such as vaginal birth after cesarean delivery, intrapartum fetal surveillance, fetal growth restriction, and shoulder dystocia have highlighted differences in definitions, causes, and recommendations. Because PPH is a leading cause of maternal morbidity and death, synthesis of national guidelines could inform schema to optimize peripartum outcomes. The purpose of this descriptive review is to compare 4 national guidelines and recommendations for 5 aspects of PPH: definition, risk factors, prevention, resuscitation, and treatment (nonsurgical and surgical).
Materials and Methods
The American College of Obstetrician and Gynecologists (ACOG) practice bulletin on PPH, guidelines from the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZOG), RCOG, and the Society of Obstetricians and Gynaecologists of Canada (SOGC) were accessed on July 1, 2014, and the data were compared. The following aspects of PPH were summarized: definition, risk factors, prevention, resuscitation, and treatment (nonsurgical and surgical). Recommendations and strength of evidence were reviewed based on each guideline’s method of reporting. Finally, the references were compared with regard to the total number of randomized control trials, Cochrane reviews, and systematic reviews/metaanalyses that were cited. Institutional review board approval was exempted because of the descriptive nature of our study and analysis.
Results
Definition
All of the guidelines used different definitions of primary PPH. The ACOG practice bulletin defines PPH as blood loss of >500 mL for vaginal deliveries and >1000 mL for cesarean delivery. The RANZOG guideline defines PPH as >500 mL during puerperium and classifies severe PPH as blood loss of >1000 mL. The RCOG guideline divides PPH into 3 categories: minor (500 mL to 1 L), moderate major (>1 L to 2 L), or severe major (>2 L). Finally, the SOGC guideline is the only organization that defines PPH qualitatively: any amount of bleeding that threatens hemodynamic stability ( Table 1 ).
| Variable | American College of Obstetricians and Gynecologists (reaffirmed 2013) | Royal Australian and New Zealand College of Obstetricians and Gynaecologists (reviewed 2014) | Royal College of Obstetrician and Gynaecologists (2011) | Society of Obstetricians and Gynaecologists of Canada (2009) |
|---|---|---|---|---|
| Definition | >500 mL (vaginal) | >500 mL during puerperium | Minor (500 mL-1 L) | Any amount threatening hemodynamic stability |
| >1000 mL (cesarean) | Severe postpartum hemorrhage >1000 mL | Moderate major (1-2 L) | ||
| Severe major (>2 L) | ||||
| Incidence | 4-6% of pregnancies | 5-15% in Australia | 3.7/1000 (>5 units packed red blood cells) | 5% of all deliveries |
| Prevention | Not discussed | Active management of third-stage labor | Active management of third-stage labor | Active management of third-stage labor |
| Determine placental location | Determine placental location | Carbetocin 100 μg over 1 minute intravenously (cesarean or vaginal + 1 risk factor) | ||
| Oxytocin, dose not specified | Oxytocin, 5 IU intravenous (cesarean delivery) | |||
| Ergometrine 0.5 mg/oxytocin 5 IU intramuscularly 2nd line | ||||
| Resuscitation | Ample intravenous access | “Massive hemorrhage protocol” activation | Intravenous access × 2 | Intravenous access × 2 |
| Crystalloid | Venous thromboembolism prophylaxis | Crystalloid, rapid, and warmed | Crystalloid solution | |
| Blood as needed | ||||
| Blood bank notification | Postpartum hemorrhage tray | |||
| Medical management | ||||
| Oxytocin-Syntocinon | 10-40 units intravenous or 10 units intramuscularly | Dose not specified, intravenous/intramuscularly | 5 units intravenous, may repeat, or 40 units intravenous in 500 mL at 125 mL/hr | 10 units intramuscularly/ 5 units intravenous or 20-40 units intravenous at 500 to 1000 mL/hr |
| Carbetocin | 100 μg intravenous over 1 minute | |||
| Ergots | Methyl-ergonovine 0.2 mg intramuscularly every 2-4 hr | Ergometrine, dose not specified | Ergometrine 0.5 mg intravenous or intramuscularly | Ergonovine 0.25 mg intramuscularly or intravenously every 2 hr |
| Prostaglandins F 2a -carboprost | 0.25 mg intramuscularly every 15-90 minutes, 8 dose maximum | 500 μg intramuscularly incrementally up to 3 mg | 0.25 mg intramuscularly every 15, 8 dose maximum or 0.5 mg intramyometrial | 0.25 mg intramuscularly every 15, 8 dose maximum |
| Prostaglandins E 2 -dinoprostone | 20 mg PV or PR every 2 hr | |||
| Prostaglandins E 1 -misoprostol | 800-1000 μg rectal | 1000 μg rectal | 1000 μg rectal | 400-1000 μg oral or rectal |
| Factor VIIa | 50-100 μg/kg every 2 hr | Base on coagulation results | Not recommended | |
| Tranexamic acid | Not recommended | Not recommended | ||
| Surgical management | ||||
| Uterine packing | 4-inch gauze, 5000 units thrombin in 5 mL saline solution | |||
| Balloon tamponade | Foley: 60-80 mL saline solution (≥1) | Type or technique not specified | First-line “surgical” intervention if caused by atony: 4-6 hr, ideally remove during daytime, deflate but leave in place | Ensure entire balloon is positioned past the cervical canal, consider antibiotic prophylaxis, 8-48 hr |
| Blakemore tube: Sengstaken technique not specified | ||||
| Bakri: 300-500 mL saline solution | ||||
| Brace suture | B-Lynch, square | B-Lynch | B-Lynch, square | B-Lynch, square |
| Vessel ligation | Uterine artery | Uterine artery | Uterine artery | Uterine artery |
| Internal iliac artery | Internal iliac artery | Internal iliac artery | Internal iliac artery | |
| Hysterectomy | Indication not specified | Indication not specified | “Sooner rather than later” second consultant recommended | Indication not specified |
| Embolization | If bleeding stable, persistent, nonexcessive | Yes, does not preclude surgical management | Yes, consider | Yes, if stable, ongoing & no surgical options |
Three guidelines (ACOG, RCOG, and SOGC) comment on the unreliability of estimated blood loss, such as using a visible estimate or through the use of blood collection drapes. None of the guidelines, however, recommended a preferred method to estimate blood loss. Despite the noted unreliability, estimates of blood loss nonetheless are used to initiate levels of treatment in RCOG guidelines. For example, minor PPH (500 mL to 1 L) should prompt basic measures such as intravenous access, indwelling bladder catheterization, full blood count and type, and screen; major PPH (estimated blood loss, >1 L) prompts a treatment protocol to achieve full resuscitation.
Risk factors
Risk factors described in the guidelines are summarized in Table 2 . All guidelines note that most women who experience PPH do not have any known risk factors; none of the guidelines provide an estimate of what proportion of women with PPH are without risk factors. The RCOG guideline is the only 1 that provides approximate odds ratios (OR) for various risk factors. Those identified as highest risk include women with suspected or proven placental abruption (OR, 13; 99% CI, 7.6–12.9), known placenta previa (OR, 12; 99% CI, 7.2–23), multiple pregnancy (OR, 5; 99% CI, 3.0–6.6), and preeclampsia/gestational hypertension (OR, 4; 99% CI, not specified), with delivery in a consultant-led maternity unit advised for women with these risk factors.
| Risk factor | National guideline |
|---|---|
| Preexisting factors | |
| History of postpartum hemorrhage | ACOG, SOGC, RCOG |
| Preeclampsia | ACOG, SOGC, RCOG |
| Overdistended uterus (macrosomia, twins, hydramnios) | ACOG, SOGC, RCOG |
| Obesity | RCOG |
| Anemia | RCOG |
| Asian or Hispanic ethnicity | ACOG, RCOG |
| Uterine anomalies (fibroid tumors) or previous uterine surgery | SOGC |
| Hereditary coagulopathies | SOGC |
| High parity | SOGC |
| Fetal death | SOGC |
| Placental factors | |
| Placental abruption | RCOG |
| Placenta previa | SOGC, RCOG |
| Fundal placenta | SOGC |
| Retained placenta | RCOG |
| Abnormal placentation | SOGC, RCOG, RANZOG |
| Intrapartum factors | |
| Prolonged labor | ACOG, SOGC, RCOG |
| Augmented labor | ACOG, SOGC |
| Rapid labor | ACOG, SOGC |
| Episiotomy | ACOG, RCOG |
| Operative delivery | ACOG, SOGC, RCOG |
| Infection (chorioamnionitis, pyrexia) | ACOG, SOGC, RCOG |
| Prolonged rupture of membranes | SOGC |
| Anesthetics, nitroglycerin | SOGC |
| Malposition | SOGC |
| Deep engagement | SOGC |
| Excessive cord traction | SOGC |
| Amniotic fluid embolism | SOGC |
| Induction of labor (oxytocin use) | RCOG, SOGC |
| Cesarean delivery | RCOG |
Women at risk for abnormal placentation and subsequent hemorrhage (such as those with a history of cesarean delivery and placenta previa) are discussed specifically in all 4 guidelines. RANZOG and SOGC guidelines recommend antenatal assessment of placentation and location in these high-risk women to prompt transfer to a tertiary care center or unit with rapid access to blood products or an intensive care unit. In addition, ACOG and RCOG guidelines recommend patient counseling about the likelihood of hysterectomy and blood transfusion, the availability of blood products, and cell-saver technology and encourage planned delivery with preoperative anesthesia assessment. None of the guidelines specify the preferred modality for evaluation of abnormal placentation (eg, ultrasound vs magnetic resonance imaging).
Prevention
There are no specific recommendations discussed in any of the guidelines with regard to PPH prevention strategies before the onset of the third stage of labor. All guidelines, with the exception of ACOG, discuss active management of the third stage of labor (AMTSL) with strong recommendations for its use in primary prevention of PPH. AMTSL traditionally involves 3 interventions that are designed to assist in placenta expulsion: uterotonics, immediate umbilical cord clamping, and controlled cord traction. Despite strong recommendation of this practice, RCOG and SOGC guidelines separate and stratify these interventions and recommend delayed cord clamping for neonatal benefit when feasible.
Oxytocin is recommended universally as the first-line uterotonic of choice for prevention of uterine atony. ACOG and RANZOG guidelines do not specify dosing or route of administration. The RCOG guideline recommends 10 units intramuscularly for uncomplicated vaginal deliveries and 5 IU intravenous slow infusion after cesarean delivery. Finally, the SOGC guideline recommends different uterotonic medications depending on the clinical scenario. For example, oxytocin 10 units intramuscularly or 5-10 units intravenously over 1-2 minutes is recommended for low-risk vaginal deliveries; carbetocin 100 μg intravenously over 1 minute is recommended for cesarean delivery or vaginal delivery in women with 1 risk factor for PPH. Carbetocin, a oxytocin analogue with a significantly longer half-life than endogenous or synthetic oxytocin, is available in the United Kingdom, Ireland, Canada, Australia, and New Zealand, but not the United States. Misoprostol is recommended by the RANZOG guideline as a second-line preventive medication or when oxytocin is not available for PPH prevention; SOGC guidelines recommends ergonovine as a second-line agent or when oxytocin is not available. Syntometrine at a fixed dose combination of 5 IU oxytocin and 0.5 mg ergometrine is recommended by the RCOG guideline as second-line prophylactic agents if available and emphasizes the higher side-effect profile of this medication.
Resuscitation
All 4 guidelines discuss resuscitative measures during PPH with emphasis on fluid management and indications for blood products. A multidisciplinary approach with strong communication with anesthesia is recommended strongly. Although the SOGC guideline suggests that institutions develop and make available specific PPH trays, RANZOG advocates institutional development of a massive transfusion protocol in cases of severe PPH, and that guideline is the only one that provides a massive transfusion protocol algorithm template. Cell-saver technology or autologous transfusion is discussed briefly in ACOG and RCOG guidelines to assist in resuscitative efforts.
Treatment
Treatment modalities, when PPH is identified, can be categorized as nonsurgical or surgical. In general, there is large variation among guidelines with regard to PPH treatment. Notably, all guidelines, except RANZOG, recommend instituting a policy or establishing a protocol when PPH is identified, yet the specifics to the protocol vary or are not established. Regarding unique nonsurgical management options, the RCOG guideline discusses pneumatic antishock gear as a temporizing measure if available, although does not specify when, in the management schema, it should be used.
Tranexamic acid, an antifibrinolytic amino acid derivative of lysine, is discussed only in RCOG guidelines. Although shown to decrease bleeding significantly in nonobstetric procedures, particularly in trauma, RCOG recommends against its use. Similarly, another antifibrinolytic medication, recombinant factor VIIa, is mentioned in ACOG, RCOG, and SOGC guidelines. It is discussed extensively in the ACOG guideline; however, indications for its use are not specified. In contrast, recombinant factor VIIa is not recommended in SOGC and RCOG guidelines as a medical treatment option for PPH.
All guidelines discuss 8 surgical techniques: (1) uterine packing, (2) balloon tamponade, (3) uterine curettage, (4) uterine artery ligation, (5) brace suture, (6) hypogastric artery ligation, (7) arterial embolization, and (8) hysterectomy. In general, less invasive fertility-sparing interventions are promoted. The SOGC guideline is the only 1 that provides figures of both B-Lynch and Cho compression suture techniques. The ACOG guideline is the only guideline that discusses the management of hemorrhage because of a ruptured uterus or inverted uterus. With regard to hysterectomy, the RCOG guideline emphasizes early recourse to hysterectomy and not delaying this decision until the woman is in extremis and further recommends subtotal hysterectomy, unless trauma to the lower uterine segment or cervix is noted. Additionally, the SOGC guideline notes that indications for hysterectomy include massive hemorrhage that is not responsive to previous interventions and that the surgical intervention chosen should be familiar to surgeons.
Tables 3 and 4 summarize all recommendations by each respective national guideline with regard to the classification or strength of evidence. Notably, none of the recommendations with either strong or weak strength of evidence are endorsed by >2 of the national guidelines that were reviewed.
| Variable | Classification (strength) of recommendation (A or B [strong]) |
|---|---|
| Definition | Clinical markers preferred over estimated blood loss quantification measures (SOGC-B) |
| Risk factors | None |
| Prevention | |
| Active management of third-stage of labor | Recommended to all women (SOGC-A and RCOG-A) |
| Oxytocin | 5-10 IU intramuscularly for management of third-stage labor without risk factors (RCOG-A, SOGC-A) |
| 20-40 IU in 1 L, 150 mL/hr acceptable alternative to active management of third-stage labor (SOGC-B) | |
| 10 units intravenously over 1-2 minutes for vaginal delivery (SOGC-B) | |
| Other | Misoprostol, if oxytocin not available (RCOG-A, SOGC-B) |
| Ergonovine 0.2 mg intramuscularly second line, more maternal side-effects (SOGC-A) | |
| Carbetocin 100 μg intravenously over 1 minute for cesarean delivery (SOGC-B) | |
| Carbetocin 100 μg intramuscularly decreases need for uterine massage in vaginal delivery (SOGC-B) | |
| Treatment | Internal iliac artery ligation, compression sutures, hysterectomy for intractable postpartum hemorrhage unresponsive to medical therapy (SOGC-B) |
| Resuscitation | All obstetric units should have emergency postpartum hemorrhage equipment tray (SOGC-B) |
| Other | Prophylactic pelvic artery occlusion for accreta is equivocal (RCOG-B) |
| Variable | Classification (strength) of recommendation (C or L [weak]) |
|---|---|
| Diagnosis | None |
| Risk factors | High clinical suspicion for conditions associated with placenta accreta (ACOG-C) |
| All women with previous cesarean delivery must rule out placenta accreta/ increta (RCOG-C) | |
| Deliver accreta/increta in facility with intensive care unit blood consultants (RCOG-C) | |
| Accelerating placenta delivery before 30-45 minutes will not reduce postpartum hemorrhage (SOGC-C) | |
| Prevention | |
| Oxytocin | 5 units intravenously for cesarean delivery (RCOG-C) |
| Other | Postpartum hemorrhage of 500-1000 mL should prompt basic resuscitation (RCOG-C) |
| Postpartum hemorrhage of >1000 mL should prompt full resuscitation protocol (RCOG-C) | |
| Syntometrine (Alliance) may be used in the absence of hypertension (RCOG-C) | |
| Intraumbilical misoprostol (800 μg) or oxytocin (10-30 IU) for manual placenta removal (SOGC-C) | |
| Treatment | Uterotonic agents should be first-line treatment for postpartum hemorrhage because of atony (ACOG-C) |
| Exploratory laparotomy is next step if uterotonics fail (ACOG-C) | |
| Mild or severe postpartum hemorrhage protocols should be initiated when identified (RCOG-C) | |
| Four components of postpartum hemorrhage management: communication/resuscitation/monitoring/investigation (RCOG-C) | |
| Recombinant activated factor VII cannot be recommended (SOGC-L) | |
| Balloon tamponade controls postpartum hemorrhage from uterine atony not responsive to medication (SOGC-L) | |
| Resuscitation | None |
| Other | Postpartum hemorrhage management requires a multidisciplinary approach (ACOG-C and SOGC-C) |
References
The number of references cited in each guideline ranges from 12 (RANZOG) to 110 (RCOG) with publication years between 1901 through 2010. Table 5 summarizes the randomized controlled trials referenced with regard to PPH prevention or treatment in the setting of vaginal or cesarean delivery. Finally, Table 6 summarizes the number of randomized controlled trials, Cochrane reviews, and systematic reviews referenced in the guidelines. Notably, the ACOG practice bulletin does not cite a single randomized controlled trial or Cochrane review in its guideline.
| Study | N a | Intervention: postpartum hemorrhage prevention | Results |
|---|---|---|---|
| Boucher et al (Canada, 2004) RCOG, SOGC | 160 | 100 μg carbetocin intramuscularly vs 10 units oxytocin infusion | No difference in need postpartum hemorrhage indicators; oxytocin group required additional uterine massage ( P < .02) |
| Gülmezoglu et al (Switzerland, 2001) SOGC | 18,459 | 600 μg oral misoprostol vs 10 units oxytocin intravenously or intramuscularly | Oxytocin group lower incidence of estimated blood loss >1000 mL, need for additional oxytocics; misoprostol with higher shivering and raised body temperature |
| Jackson et al (United States, 2001) SOGC | 1486 | 20 units oxytocin intravenous bolus before or after placenta delivery | No difference in need for additional oxytocics, postpartum hemorrhage incidence, third-stage duration, incidence of retained placenta |
| Leung et al (Hong Kong, 2006) RCOG, SOGC | 329 | 100 μg carbetocin intramuscularly vs 1 mL Syntometrine (5 units oxytocin + 0.5 mg ergometrine) | No difference in hemoglobin concentration, need for additional oxytocics, postpartum hemorrhage, or retained placenta; carbetocin had lower nausea, vomiting, hypertension but higher maternal tachycardia |
| Nordström et al (Sweden, 1997) SOGC | 1000 | Intravenous oxytocin vs saline solution | Oxytocin reduced mean total blood loss, postpartum hemorrhage frequency, need for additional oxytocics, and postpartum hemoglobin <10 g/dL |
| Parsons et al (Netherlands, 2007) SOGC | 450 | 800 μg rectal misoprostol vs 10 units oxytocin intramuscularly | No difference in hemoglobin; shivering more common in misoprostol group |
| Boucher et al (Canada, 1998) RCOG | 114 | 100 μg carbetocin vs oxytocin infusion | Carbetocin mean blood loss 41 mL less, increased uterine involution, decreased need for additional oxytocics |
| Dansereau et al (Canada, 1999) RCOG, SOGC | 694 | 100 μg carbetocin vs oxytocin infusion | Carbetocin reduced need for additional oxytocic intervention |
| Chou and MacKenzie (Taiwan, 1994) RCOG | 60 | 0.125 mg prostaglandin F 2 alpha vs oxytocin 20 units intravenously | No difference in estimated blood loss, hemoglobin, side-effects |
| Lokugamage et al (United Kingdom, 2001) RCOG | 40 | 500 μg oral misoprostol vs 10 units oxytocin | No difference in estimated blood loss, need for additional oxytocics, need for transfusion, degree of shivering |
| Munn et al (United States, 2001) RCOG | 321 | 10 U/500 mL vs 80 U/500 mL oxytocin intravenous infusion over 30 min | Additional uterotonics required in low dose group, similar rate of hypotension |
| Postpartum hemorrhage treatment | |||
| Blum et al (multiple countries, 2010) RANZOG | 809 | 800 μg misoprostol vs 40 units intravenous oxytocin | No difference in bleeding parameters, shivering; fever more common in misoprostol arm |
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