Journal Pre-proof

Prevention of postpartum hemorrhage

Veronica Gonzalez-Brown, Patrick Schneider

PII: S1744-165X(20)30054-8
DOI: https://doi.org/10.1016/j.siny.2020.101129
Reference: SFNM 101129

To appear in: Seminars in Fetal and Neonatal Medicine

Please cite this article as: Gonzalez-Brown V, Schneider P, Prevention of postpartum hemorrhage,
Seminars in Fetal and Neonatal Medicine, https://doi.org/10.1016/j.siny.2020.101129.

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Prevention of postpartum hemorrhage

Veronica Gonzalez-Brown, MD1 & Patrick Schneider, MD2

1
Fellow, Division Maternal Fetal Medicine, Department of Obstetrics and Gynecology, the Ohio
State University College of Medicine, Columbus, OH
2
Assistant Professor, Division Maternal Fetal Medicine, Department of Obstetrics and
Gynecology, the Ohio State University College of Medicine, Columbus, OH

Conflict of Interest: The authors report no conflict of interest.

Funding: No outside funding support was provided to conduct research.

Disclaimer: The opinions and assertions contained herein are the private opinions of the authors
and are not to be construed as official or reflecting the views of the Ohio State University,
Department of Defense, or the Uniformed Services University of the Health Sciences.

Corresponding author:

Patrick Schneider, MD
395 West 12th Avenue, 5th floor
Columbus, OH 43210
Cell number: 724-799-1039
Email: Patrick.Schneider@osumc.edu

Short title: Advances in obstetric hemorrhage prevention

Key words: Obstetrical hemorrhage, massive transfusion, prevention, postpartum hemorrhage,

management
Abstract
Postpartum hemorrhage is a leading cause of severe maternal morbidity and mortality worldwide

and the United States. While the rates of maternal mortality attributable to hemorrhage are

declining, severe maternal morbidity continues to be a growing problem. Efforts in recent years

to more appropriately identify patients at risk, define significant hemorrhage, quantify blood

loss, and standardize approaches to care in pregnancy and postpartum have led to an increasing

preventability of PPH. We aim to review the most current recommendation for the prevention

and effective management of obstetric hemorrhage.

Introduction

Postpartum hemorrhage is the most common obstetrical complication of childbirth.1 While

maternal mortality in the United States attributable to hemorrhage has been decreasing, with a

reported rate of 11.2% between 2011-2015, the incidence of hemorrhage have continued to

increase.2 Globally, these rates are even higher, especially in lower resource countries, but have

also shown trends towards improvement in overall hemorrhage attributable mortality.3 However,

with the improvements in mortality, there appears to be increased rates of severe maternal

morbidity (SMM) including transfusion > 4 units of packed red blood cells and hysterectomy.2,4

In addition to the direct consequences resulting from acute hypovolemia, PPH exposes women to

complications of transfusion, resuscitation, thromboembolic events, pituitary necrosis, infertility

when treated with hysterectomy, and increased psychological stress.2,4-6

Efforts at decreasing morbidity and mortality have been increasingly well described and

characterized. Within the United States, state- and hospital-level quality improvement initiatives

have noted significant gains in decreased maternal mortality and SMM while reducing racial

disparities.7,8 Their comprehensive approaches that combine evidence-based toolkits, bundles,

checklists, and triggers for care empower healthcare teams with the necessary guidance and

support to develop care processes that can effectively address the potentially avoidable issue of

hemorrhage.

Over the course of this review, we will discuss the prevention of hemorrhage through system-

and patient-level processes. Those processes will then be connected to appropriate interventions

and care in the setting of postpartum hemorrhage.

Changing Definitions

Traditionally, PPH was defined as an estimated blood loss greater than 500ml following a

vaginal delivery or 1000ml a cesarean delivery.1 In 2014, ACOG published the reVITALize

initiative, reclassifying the definition of PPH as cumulative blood loss greater than or equal to

1000ml or blood loss that is related with signs or symptoms reflecting hypovolemia within the

first 24 hours of the birthing process.9 The new classification by ACOG provides a consensus on

the definition and may reduce the number of patients diagnosed with PPH while still recognizing

the need for prompt and attentive care. Despite this new definition, a vaginal delivery with blood

loss exceeding 500ml should not be considered the norm and should trigger further evaluation to

cause of blood loss.1,9

However, these standards in the United States are not necessarily carried over elsewhere in the

world. In 2015, Dahlke and colleagues performed a review of the national practice guidelines

from the Royal College of Obstetrics and Gynecology (RCOG), Royal Australian and New

Zealand College of Obstetricians and Gynecologists (RANZOG), Society of Obstetricians and

Gynaecologists of Canada (SOGC) and the American College of Obstetrics and Gynecologists

(ACOG) to compare the definition, risk factors, prevention strategies, resuscitation measures and

treatment. Their findings demonstrated significant differences between the four national

guidelines in their designation of PPH suggesting the further need for better evidence and

cohesion in care guidance and recommendations.10

Significantly, though, the guidelines did share commonalities showing evolution in approaching

the diagnosis and recognition of PPH. Notable among these developments was the shift to
recommendation of avoiding blood loss estimates either visually or through retrospective

calculation.10 Several studies have shown that visual estimates of postpartum blood are not

reliable and lead to overestimation or underestimation of quantity of bleeding, even for

experienced physicians.11 A decrease in hematocrit by 10% was historically another marker that

defined PPH.1,12 However, this decrease and other similar markers are obviously delayed and

may not reflect current hematologic status thereby limiting their usefulness in the setting of acute

PPH.

All of the guidelines from Dahlke et al.’s review expressed that quantifiable methods of blood

loss determination are preferable.10 Objective methods to measure blood loss directly have been

proposed to include the use of a collecting bag, weighing of compresses, and electronic scanning

systems. These quantified processes show high correlation between their measured blood losses

and predicted postoperative hemoglobin values compared to visual estimations of blood loss.13,14

The challenge with these newer systems, unfortunately, has been issues with their

implementation into routine clinical care, as well as, the recognition that their use does result in a

decrease in the incidence of severe PPH.11,14-16 However, compared to the previous inaccuracies

of visual estimation, the quantified blood loss offers the best opportunities for accuracy and

precision in care and will likely continue to increasingly become standard practice.

Systems-Level Prevention

The goal of a healthcare system is to prepare as adequately and thoroughly as possible, while

recognizing and accommodating to the limitations of the resources available to it. Whether that

is the individual provider or a network of hospitals, preparation is crucial to provide the most
effective care. Accordingly, systems must provide access to educational materials, adequate

support for timely diagnosis and intervention, and appropriate contingencies to empower

healthcare workers to address care needs during prenatal, delivery, and postpartum care.17

Educational resources have historically taken the form of lectures and reading materials. While

these methods allow for exposure to commonalities of language and standards of care, they are

insufficient alone to alter and change suboptimal clinical practice within an institution.

Increasing evidence suggests that the role of simulations and drills may have a more meaningful

impact on affecting change.18 While simulations may not be immediately available given the

need for substantial investments in models and technological processes to aid in their function,

drills are usually more accessible and implementable for institutions.19 Moreover, examples for

their effective use are publicly available.17

In addition to these educational formats, systems taking efforts to establish care pathways can aid

in overcoming barriers to care. Checklists, bundles and toolkits that cover the contents of

hemorrhage kits containing appropriate uterotonic agents (hemabate, methylergonovine,

misoprostol, oxytocin, tranexamic acid) and instruments (intrauterine balloon tamponade) for

bedside use, as well as, algorithms for appropriate escalation of care allow for standardized

responses to instances of hemorrhage, limiting worsening of the hemorrhage.17 This can also

involve incorporation of risk factor assessment to identify patients during their prenatal care and

at the time of delivery that may be at increased risk for hemorrhage, warranting closer attention

and monitoring (Figure 1).17,20

Patient-Level Prevention

Even the best system-level preparation may not always be able to address individual patient

needs that derive from patients’ specific medical conditions and personal beliefs. However,

recognition of common patient conditions and types that may be encountered allows for

application of a framework for processing specific conditions that place patients at elevated risk

for adverse outcomes. The conditions here are not an exhaustive list. They instead represent

examples of conditions that will likely be encountered in the course of obstetrical patient care

and the increased risk for hemorrhage that they have.

Morbidly Adherent Placenta

Placental accreta spectrum (accrete, increta, percreta) refers to abnormal adherence of the

placenta at the endometrial-myometrial interface that leads to aberrant decidualization.21 It is

estimated that morbidly adherent placental disease complicates 1 in 272-553 pregnancies.21,22

Risk factors for placenta accreta spectrum include advanced maternal age, multiparity, prior

uterine surgeries, placenta previa and Asherman Syndrome. The most common risk for placenta

accreta, though, is history of prior cesarean deliveries.21 The rate increases from 0.3% for

women with a history of one prior cesarean section to 6.74% for women with history of five or

more cesarean deliveries.22

The optimal timing for diagnosis of placenta accreta is antenatally. Ultrasonography is the

primary method used for diagnosis. When performed by experienced, trained sonographers,

ultrasound has a 77-87% sensitivity and 96-98% specificity as a diagnostic tool.23,24 MRI is

another tool that can be used in diagnosing placenta accreta spectrum. While accuracy of MRI in
predicting placenta accrete is relatively good, there is no evidence that it is superior to

ultrasonography.25

When placenta accreta is suspected at a vaginal delivery, attempts to continue to remove the

placenta should halt. If patient is not in the operating room, then the patient should be transferred

to the operating room for continued evaluation and management. The assessment in the operating

room should encompass appraisal of placental attachment abnormality. Patients should be

counseled on likely need for blood transfusion. If there is continued bleeding, then hysterectomy

should be considered.21,26

Inherited Coagulation Disorders

Coagulation involves a series of complex reactions between proteins designed to aid in

hemostasis. Genetic conditions affecting the functioning and presence of these proteins may lead

to issues before, during, and after delivery. Fortunately, many of these are well-characterized,

testable, and treatable.27

The most commonly identified coagulation disorders include: von Willebrand Disease,

Hemophilia A (Factor VIII deficiency), Hemophilia B (Factor IX deficiency), and Hemophilia C

(Factor XI deficiency). The specific descriptions of these conditions, their confirmatory tests,

and appropriate treatment is beyond the scope of this review, but are available.17,27 More

importantly, the finding of these conditions should prompt multidisciplinary care coordination

with appropriate Maternal-Fetal Medicine, Anesthesiology, and Hematology consultation where

available.
Patients Refusing Blood Products

While the refusal may be for religious reasons or personal convictions, the need to address these

patients’ care plan early in pregnancy is paramount. Candid and frank conversations about what

is and is not acceptable in terms of products that may be administered, as well as, appropriate

supplementation to maintain maximally elevated hemoglobin levels are both achievable and

generally well-tolerated by patients. Decision aids can help open dialogue about products that

may or may not be acceptable to patients, empowering them to continue conversations if they

choose to do so with their family or other trusted advisors.17

Additionally, principles that can help optimize their care may also be used to structure care in

other areas such as those with iron-deficiency anemia.

Recognition

Differential Diagnosis:

Most cases of acute blood loss anemia that are life-threatening arise from primary PPH,

occurring within the first 24 hours after delivery. Accordingly, most of the scientific literature

and the management guidelines concern primary PPH.1 While secondary PPH, occurring from

24 hours to 6 weeks after delivery, is a recognized and well-described issue, it is rarer and more

specific in its causes.28,29 Figure 2 notes the usual primary and secondary sources of postpartum

hemorrhage.1,17,28,29

Diagnosis of PPH begins with appreciation of acute bleeding and evaluation to determine cause

and source of bleeding. A careful and quick examination can identify the origin of bleeding and

dictate the proper course of action.1,26 Uterine atony is estimated to be the cause of PPH in about
70-80% of cases.30 Obstetrical trauma, such as laceration and wounds, account for 15-20% of

excessive bleeding after delivery.11 Retained placental tissue is another common cause of PPH

and accounts for approximately 10-30%.26

Uterine Atony

Uterine atony should be suspected when bleeding is accompanied with a soft, poorly contracted

uterus. Initial management should include pelvic exam, removal of intrauterine clots, emptying

of bladder, and uterine massage. 1 Uterotonic agents should be employed; these can include

oxytocin, ergot alkaloids, and prostaglandins.17

Oxytocin is the most effective uterotonic for PPH, even if previously used for induction or

augmentation of labor.31 In up to one quarter of events, a second uterotonic in addition to

oxytocin will be warranted.32 There is lack of evidence to recommend which additional

uterotonic is most effective. The choice of subsequent agent should be patient-specific based on

factors such as history of asthma or hypertension.1,33 Tranexamic acid is not a uterotonic but may

be considered as an adjuvant therapy for PPH.34 Atony that is refractory to medical management

may necessitate higher-level procedural interventions which will be discussed later in the review.

Obstetric Trauma/Lacerations

Lacerations of the genital tract can also be a source of postpartum bleeding. Prompt

identification of the origin of bleeding and repair of the laceration is the primary step in

controlling the bleeding. The clinician should not hesitate to transfer patient to operating room

for better visualization and to consult anesthesia for pain management.1

Hematomas of the genital tract are also a source of significant blood loss. They may present with

pelvic pressure/discomfort or changes in vital signs. Small hematomas may be managed

conservatively. Hematomas that continue to demonstrate signs of volume loss or rapidly enlarge

may require surgical incision and evacuation. If the patient is hemodynamically stable,

management with arterial embolization should be considered.26

Uterine inversion is a rare source of PPH, occurring in 0.04% of deliveries. Patient with inverted

uterus may present with signs of shock without excessive bleeding. Once recognized, swift

attempt to replace uterus should be made. If uterus is not able to easily be replaced, then

magnesium sulfate, terbutaline, nitroglycerin, or general anesthesia may be necessary to facilitate

uterine relaxation for manipulation. Once uterus is returned to its position, uterotonics are

employed to promote uterine tone and decrease chance of recurring.26

Intraperitoneal and retroperitoneal bleeding should be high on the differential when a patient has

deterioration of vital signs with no obvious source of bleeding, especially after cesarean section

or instrumental vaginal delivery. If suspected, it is generally advisable to choose the appropriate

course of care based on the hemodynamic status of the patient. Hemodynamically unstable

patients should be taken to an operative room for surgical correction while continuing to receive

resuscitation. Diagnostic imaging or interventional radiology procedures should only be

considered in hemodynamically stable patients.1,26

Management

Active management of third stage of labor

Active management of the third stage of labor has been strongly suggested as a means to reduce

the incidence of PPH.17,35 This involves prophylactic administration of oxytocin immediately

after delivery of neonate, uterine massage and umbilical cord traction. According to the

Cochrane review by Begely et al, active management for women at varied levels of risk for

hemorrhage compared to expectant management (i.e. signs of placental separation, spontaneous

delivery of placenta) noted a reduced rate of PPH>1000mL (average risk ratio (RR) 0.34,95%

confidence interval (CI) 0.14 to 0.87) and Hb<9g/dL (average RR 0.50, 95% CI: 0.30 to 0.83). It

was also associated with a significant decrease in primary blood loss >500mL, mean maternal

blood loss at birth, maternal blood transfusion, and therapeutic uterotonics during the third stage

of labor and/or within the first 24 hours after delivery. Findings were similar for the subgroup of

women at low risk of excessive bleeding, except that the groups did not differ significantly for

either blood loss >1000ml (severe hemorrhage) or maternal Hb<9g/dL at 24 to 72 hours.35

Prophylactic oxytocin has been an effective medication with minimal side effects and is

recommended to be administered after all births for prevention of PPH.31 In a Cochrane review

from Salati et al the efficacy of prophylactic oxytocin was noted to reduce the risk of blood loss

>500mL and the risk of blood loss >1000mL by approximately 50%. The optimal time for

oxytocin administration, however, has not been found to be associated with risk of hemorrhage.31

The current recommendations by national organizations to include ACOG, World Health

Organization (WHO), and Association of Women’s Health, Obstetric and Neonatal Nurses

(AWHONN) is for the administration of prophylactic uterotonics after delivery of neonate.1,36

Management of Acute Blood Loss

Ultimately, prompt and effective management in the setting of an actively bleeding pregnant and

postpartum patient requires providers to understand the likely etiologies as well as the tools

available to them to appropriately escalate care. While the available resources will differ from

center to center, an appreciation of what is available for various conditions can allow for

appropriate dispensation of care. An example of a general surgical approach to postpartum

hemorrhage management is provided in Figure 3.37

Medical management

Uterotonics are the mainstay first line agents for PPH. This is mostly due to the fact that PPH is

usually caused by uterine atony. Oxytocin is the uterotonic most widely used and, thus, most

thoroughly studied. Compared with placebo, oxytocin reduces the risk of PPH >500 mL (RR

0.51; 95% CI: 0.37–0.72), of severe PPH >1000mL (RR 0.59; 95% CI: 0.42–0.83), and of the

need for supplementary uterotonics (RR 0.54; 95% CI:0.36–0.80). This finding was observed

whether it was administered intravenously or intramuscularly.31

Ergot alkaloids are common uterotonics that can be used alone or in combination with oxytocin.

Administration of ergot derivatives reduces the incidence of PPH compared with placebo for

PPH >500mL (RR 0.52; 95% CI: 0.28–0.94) and severe PPH (RR 0.32; 95% CI: 0.04–2.59) but

at the cost of frequent adverse effects, most especially hypertension (RR 2.60; 95% CI: 1.03–

6.57).38 Ergot alkaloids are associated with reported side effects to include myocardial infarction,

stroke and hypertensive encephalopathy.38 Caution should be exercised when using this

medication especially in women with hypertensive disorders of predisposition for vascular

disease.28,38
Carboprost tromethamine (Hemabate) is the synthetic 15-methyl analogue of prostaglandin F2α.

This has been reported to be 84–96% effective in the treatment of persistent hemorrhage due to

uterine atony.39 Carboprost may cause prostaglandin-like side-effects, including nausea,

vomiting, diarrhea, headaches, hypertension and bronchial asthma due by the contraction of

smooth muscles.39 There have been few studies looking at carboprost and prevention of PPH. In

a study by Abdel-Aleem and colleagues, carboprost was compared to methylergometrine. The

duration of the third stage of labor and mean blood loss were significantly less in the carboprost

group.40 In a similar study by Vaid et al, prophylactic sublingual misoprostol, intramuscular

methylergometrine and intramuscular carboprost were compared during the active management

of the third stage of labor, and it was observed that the three drugs were equally effective in the

prevention of PPH, although diarrhea was more common in the patients who received

carboprost.41

Misoprostol is another uterotonic derived from prostaglandins. Misoprostol differs from the other

uterotonics, in that in only comes in tablet form and allows for oral, vaginal or rectal

administration. Oral or sublingual misoprostol compared with placebo is effective in reducing

severe PPH (RR 0.66; 95% CI: 0.45–0.98) and blood transfusions (RR 0.31; 95% CI: 0.10–

0.94).42 In a cochrane database review comparing oral misoprostol to other uterotonics (oxytocin

IV or IM, methylergometrine, and syntometrine), oral misoprostol administration was associated

with an increased risk of severe PPH (RR 1.33; 95% CI:1.16–1.52). The review noted that

misoprostol at doses equal or greater than 600 µg was associated with more side effects, than at
doses of 400 µg.42 Additionally, it does not appear that misoprostol is superior to any other

uterotonic and may be more effective when used in combination with other uterotonics.43

Tranexamic Acid (TXA) is an antifibrinolytic reduces transfusion rates in elective surgery

patients, mortality in bleeding trauma patients, and menstrual blood loss in women with

menorrhagia.44 Several randomized trials have evaluated the efficacy of TXA in preventing PPH

after cesareans and vaginal deliveries. The studies found decreased blood loss in the TXA group,

and all the meta-analyses showed a significant reduction in postpartum blood loss, PPH, severe

PPH, and transfusions in the TXA group compared with the control group.44 The WOMAN trial,

a large randomized international trial, compared 1gram of intravenous tranexamic acid to

placebo in women with PPH. This study noted mortality rates from obstetric hemorrhage were

1.2% versus 1.7% when comparing tranexamic acid to placebo (P=0.008) when given within 3

hours of delivery.34 Nevertheless, data is insufficient to recommend TXA as a prophylaxis for

PPH, but should be considered in the management of PPH when initial therapy fails.1

Procedural Interventions

When medical therapy and uterine massage is not successful at controlling PPH, then other

adjunct measures may be necessary to employ to control bleeding. Intrauterine compression can

be effective in decreasing bleeding. This can be accomplished with uterine packing or balloon

tamponade. The evidence on its benefits is limited, however, the reported effectiveness, defined

by absence of need for surgical intervention or interventional radiology, ranges from 75-86%.45

Even if tamponade is not completely successful, it does provide time for continued resuscitation
and stabilization. This can also allow for interhospital transfer, if necessary, to transfer patient to

more appropriate facility or if arterial embolization is being considered.17

Uterine artery embolization is another alternative for the management of PPH. This procedure is

limited to patient that are hemodynamically stable, as well as, embolization unit nearby. Success

rate is estimated up to about 90%, and the serious complication rate attributable to embolization

is approximately 5%. Infertility after embolization has been reported in up to 43%; if pregnancy

post embolization is successful, available studies report no difference in pregnancy

complications compared to general population.46-48

With the lack of studies comparing the effectiveness of different surgical techniques, no

technique for conservative surgical management should be preferred over another. Vascular

ligation allows for the control of bleeding by diminishing the pulse pressure of uterine blood

flow.1 Bilateral uterine artery ligation is a straight-forward and quick procedure that decreases

blood flow to uterus with a low risk of serious complications.28 Historically, internal iliac artery

ligation was a preferred method but has fallen out of favor. Internal iliac artery ligation is not as

successful as previously thought and obstetric surgeons have become less familiar with

procedure. Bilateral uterine artery ligation is reported to have a success rate of approximately

90%.11

Uterine compression sutures have been shown to be effective as a secondary treatment for PPH

caused by atony unresponsive to medical management. The success of uterine compression

sutures appears to be approximately 60-75%.11Several techniques have been described in

literature, but the B-Lynch technique is the most commonly performed.37,49 However, no uterine

compression technique has been demonstrated to be superior to any another in the treatment of

PPH.28,37

In cases of failed medical and other uterine-sparing procedures, massive PPH, or unstable

hemodynamics, peripartum hysterectomy should be considered in a timely manner. This

procedure is associated with sterility, as well as, potential surgical complications. There are

limited number of studies and published work that report bladder injuries occurring from 6-12%

and ureteral injuries 0.4-40% during a peripartum hysterectomy.1,50 However, there is no data

comparing success of hysterectomy to other management techniques. There is equally, limited

data on best approach to hysterectomy. Thus, the surgical approach to hysterectomy is left to the

surgeon’s discretion.1,37,51

Transfusion Strategy

Acute coagulopathy remains a major complication in the setting of massive hemorrhage.

Recent data from the non-obstetric literature suggest transfusion of packed RBC concomitantly

with platelets and FFP at a ratio as close to 1:1:1 as possible. This has been shown in several

retrospective studies in military and civilian trauma settings to reduce mortality by 15-62%

compared with higher ratios of FFP:PRBC.52 While this data showed survival was improved, the

retrospective nature of these studies are limited by survival bias and they did not include

pregnant women.53
While there is nearly universal support for obstetric hemorrhage protocols, there is inconsistency

among obstetric societies regarding composition of obstetric hemorrhage massive transfusion

protocols (MTP). The CMQCC recommends that emergency release and massive transfusion

protocols should be in place, and resuscitation transfusion should be based on vital signs and not

be delayed by waiting for laboratory results.17 Further recommendations by the CMQCC include

an initial blood release package containing 4–6 RBC units, 4 plasma units and one platelet dose,

with transfusion to be guided by laboratory markers if time permits.17

Another safe and effective technique that has been shown to be effective and safe in obstetric

patients is intra-operative cell salvage.54 Use of cell salvage has historically been controversial

due to thoughts of increased risk of amniotic fluid embolism. However, with the advent of

improved filter systems there is no evidence of increased risk with this technique as described

previously in obstetric literature.55 A patient receiving salvaged blood should undergo screening

with a Kleihauer-Betke stain and appropriate administration of anti-D immunoglobulin is

required for prevention of allow immunization in Rh-negative blood type.54 The biggest

challenge with intraoperative cell salvage are due to availability, equipment and unpredictability

of PPH. In settings where significant blood loss is anticipated, cell salvage may be an excellent

tool to have available.1,54

Recombinant factor VII a (rFVIIa) has been reported to be used in obstetric hemorrhage

protocols unresponsive to transfusion. Traditionally, this therapy has been approved for patients

with hemophilia and inhibitory alloantibodies. However, it has been used off label in various
clinical scenarios including trauma, cardiovascular surgery, and obstetrical hemorrhage; and is

being added to many massive transfusion protocols. Concerns exist regarding the risk of rFVIIa

use in PPH, especially considering that the period of greatest baseline thromboembolism

risk has been reported in the first week following delivery.1 These concerns are underscored by

the reported thromboembolic risk in rFVIIa off-label use for hemorrhage management.56

Multiple, non-obstetric, randomized controlled trials have been published where rFVIIa has been

used to control bleeding, and none showed that its use improves survival. However, 4 out of 17

studies concluded that it reduced transfusion requirements or blood loss.57 The optimal dose of

rFVIIa in pregnancy is unknown, but there are reports in the obstetrical literature where dose of

40 - 90 micrograms/kg are recommended.58

Conclusion

Postpartum hemorrhage is a leading cause of maternal morbidity and maternal mortality

worldwide. While there have been improvements in preventing and effectively managing PPH

through the increasing use of well-published protocols, toolkits, and bundles of care, there

remain continued opportunities for improvement and implementation. Prevention can and

should be aimed at all pregnant and postpartum women with system-level structural changes to

the delivery of care and tailoring care for individual patient care needs through the adoption and

incorporation of publicly available resources.

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Figure 1: Risk factors for hemorrhage at admission/labor

Factors that increase risk for hemorrhage at Admission:

Low Risk Moderate Risk High Risk
Singleton pregnancy Prior uterine surgeries Placenta previa
≤4 prior vaginal deliveries Multifetal gestation Suspected placenta accreta
syndrome
No known bleeding disorder >4 prior vaginal deliveries Hematocrit<30 (%) AND risk
factors
No prior history of PPH Prior history of PPH Platelets < 100 (x103/µL)
Uterine fibroids Active bleeding on admission
Known coagulopathy
Factors that may develop in labor increasing hemorrhage risk:
• Prolonged second stage
• Prolonged oxytocin use
• Active bleeding
• Chorioamnionitis
• Magnesium sulfate infusion in labor
• Operative assisted birth (Vacuum/forceps)
• Retained placenta

Figure 2 Etiology of Postpartum

Hemorrhage
• Primary (Early) Causes:
o Uterine atony
o Pelvic trauma
o Retained tissue
o Coagulopathic disorders
o Uterine Inversion
o Abnormal placentation

• Secondary (Late) Causes:

o Subinvolution of placental site
o Retained products of conception
o Abnormal placentation
o Coagulopathic disorders
o Infection
o Uterine pathology
FIGURE 3: Algorithm for Surgical Management of PPH

• Team-based approach
o Closed loop communication
o Assign team member roles
• Management of Supplies
o Hemorrhage care readily available
and stocked
o Uterotonics
o Intrauterine compression device
o Uterine tamponade/balloon
o Ultrasound
o Dilation and Curettage equipment
o Cesarean hysterectomy tray
o Cystoscope and tower
● Blood loss Monitoring
o Quantitative & qualitative
assessment
o Readback of EBL at regular intervals
● Hemodynamic Support
o Massive transfusion protocol, as
indicated
o Anesthesia
o Antibiotics, redosed as necessary
● Optimization in Operating Room
o Proper patient position
o Optimization of lighting
o Resources/Team members readily
available
● Full systematic assessment and treatment
o Evaluate for source of bleeding
o Bedside ultrasound
o Manual exploration
o Assist abdominally, if not already
open
o Evaluate pelvis in systematic fashion
o Evaluate non-pelvic organs