Practice Issues
What Is New in Insights and Strategies in
Postpartum Hemorrhage?
Best Articles From the Past Year
Rebecca Dunsmoor-Su, MD, MSCE
T his month we focus on
current research in
postpartum hemorrhage.
Dr. Dunsmoor-Su dis-
cusses five recent publica-
tions, which are concluded
with a “bottom line” that is
a take-home message. A
complete reference for
each can be found in Box
1 on this page along with
direct links to abstracts.
(Obstet Gynecol 2018;0:1–3)
DOI: 10.1097/AOG.0000000000002713
Postpartum hemorrhage is defined as a cumulative
blood loss greater than 1,000 mL accompanied by
signs and symptoms of hypovolemia. Additionally, it
can be defined by a postdelivery hematocrit decrease
of 10% or more. While the definition is not standard-
ized when looking between publications (including
between the publications highlighted here), the
sequelae are well-recognized worldwide, with up to
100,000 deaths worldwide each year from bleeding
complications within 24 hours of delivery.1 In review-
ing the breadth of studies published this year relating
to the topic of postpartum hemorrhage, we can recog-
nize where improvement in management may be able
to save lives. It is also important to recognize that
standardization of definition and research methodol-
ogy would increase the generalizability of results.
Dr. Dunsmoor-Su is from the Obstetrix Medical Group at the Swedish Medical
Center, First Hill Campus, Seattle, Washington; email: rdunsmoorsu@gmail.
com.
Financial Disclosure
The author did not report any potential conflicts of interest.
© 2018 by the American College of Obstetricians and Gynecologists. Published
by Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0029-7844/18
VOL. 0, NO. 0, MONTH 2018
Copyright Ó by American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
Box 1. Abstracts Discussed in This Commentary
1. Sirico A, Saccone G, Maruotti GM, Grandone E,
Sarno L, Berghella V, et al. Low molecular weight
heparin use during pregnancy and risk of postpar-
tum hemorrhage: a systemic review and meta-
analysis. J Matern Fetal Neonatal Med 2018 Jan 5.
Available at: http://dx.doi.org/10.1080/14767058.
2017.1419179.
2. Kohn JR, Dildy GA and Eppes CS. Shock index and
delta shock index are superior to existing maternal
early warning criteria to identify postpartum hem-
orrhage and need for intervention. J Matern Fetal
Neonatal Med 2018 Feb 4. Available at: http://dx.
doi.org/10.1080/14767058.2017.1402882.
3. WOMAN Trial Collaborators. Effect of early
tranexamic acid administration on mortality, hyster-
ectomy, and other morbidities in women with post-
partum haemorrhage (WOMAN): an international,
randomized, double-blind, placebo controlled trial.
Lancet 2017; 389:2105–16. Available at: http://dx.
doi.org/10.1016/S0140-6736(17)30638-4.
4. Çetin BA, Aydogan Mathyk B, Atis Aydin A, Koroglu
N, Yalcin Bahat P, Temel Yuksel I, et al. Comparing
success rates of the Hayman compression suture
and Bakri balloon tamponade. J Matern Fetal Neo-
natal Med 2018 Apr 2. Available at: http://dx.doi.
org/10.1080/14767058.2018.1455184.
5. Thurn L, Wikman A, Lindqvist PG. Postpartum
blood transfusion and hemorrhage as independent
risk factors for venous thromboembolism. Throm
Res 2018;165:54–60. Available at: http://dx.doi.
org/10.1016/j.thromres.2018.03.002.
Low Molecular Weight Heparin Use During
Pregnancy and Risk of Postpartum Hemorrhage: A
Systematic Review and Meta-analysis
In this meta-analysis and systematic review, the
authors do a good job of assessing studies for
heterogeneity and quality before including them in
OBSTETRICS & GYNECOLOGY 1
the analysis. Only studies looking at postpartum
hemorrhage as the main outcome were assessed,
though the definitions of postpartum hemorrhage
varied. In all of the studies, women were included
only if on low-molecular-weight heparin (LMWH) in
the third trimester, but not at delivery or immediately
after. In the end, a total of eight studies met inclusion
criteria, with a resultant 1,320 exposed women and
20,842 control participants assessed. Overall assess-
ment of the studies showed a low risk of publication
bias. The overall risk of postpartum hemorrhage in
women receiving LMWH was elevated at 1.45 (CI
1.04–2.04). The mean blood loss and risk of transfu-
sion at delivery were not significantly different; how-
ever, these subanalyses contained only a small subset
of the original studies because not all reported these
variables. A large prospective study on this topic
would be warranted.
Bottom Line: The use of LMWH in pregnancy does
seem to confer a higher risk of postpartum hemor-
rhage at delivery, though mean blood loss at delivery
and transfusion risk do not seem to be affected. This
information can help to risk-stratify women at
delivery.
Shock Index and Delta-Shock Index are Superior to
Existing Maternal Early Warning Criteria to Identify
Postpartum Hemorrhage and Need for Intervention
This is a small retrospective analysis designed to
determine whether a larger prospective study is
worthwhile to assess the ability of the shock index
and a novel parameter, the delta shock index, to be
effective early-warning markers to help determine
which women experiencing postpartum hemorrhage
require more aggressive interventions. Shock index is
the heart rate divided by the systolic blood pressure,
and the authors define delta shock index as the change
between the peak shock index and the baseline shock
index, which is taken from the patient’s last prenatal
visit. They assessed these parameters for their ability
to predict postpartum hemorrhage, transfusion need,
and the need for surgical intervention. They con-
cluded that a shock index up to 1.1 can be normal
in the peripartum period (in other scenarios, normal
ranges from 0.5 to 0.7). They found that shock index
greater than 1.143 and shock index greater than 1.412
were strong and critical thresholds for predicting the
above outcomes and that delta shock index was the
most sensitive predictor. They also found that, in pre-
eclampsia, parameters are skewed and would require
different cutoffs; however, there were not enough data
in this study to determine these. The prospective
2 Dunsmoor-Su What’s New in Postpartum Hemorrhage?
Copyright Ó by American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
study they propose could lead to a more sensitive
and patient-specific indicator of elevated bleeding
risk.
Bottom Line: These sensitive parameters, especially
the delta shock index, may be helpful at predicting
which patients need more urgent intervention in the
setting of postpartum hemorrhage.
Effect of Early Tranexamic Acid Administration on
Mortality, Hysterectomy, and Other Morbidities in
Women With Postpartum Haemorrhage (Woman):
An International, Randomised, Double-Blind,
Placebo-Controlled Trial
The main outcome of this large, multicenter, random-
ized controlled trial (RCT) was the risk of death from
postpartum hemorrhage. Originally the authors were
going to assess a composite of risk of hysterectomy
and death; however, they found that the decision for
hysterectomy was being made at the same time as
randomization, so this would be an invalid endpoint.
They increased the number enrolled to assess for
death as the primary outcome. Women were given
either 1 g of tranexamic acid (TXA) or placebo while
continuing all other interventions. A second dose (of
TXA or placebo) could be given if bleeding stopped
and then restarted within 24 hours of the first bleed.
The overall risk of death from postpartum hemor-
rhage was decreased in women given TXA (155/
10,036 [1.5%]) vs placebo (191/9,985 [1.9%]; relative
risk 0.81). This correlates to an approximate number
needed to treat of 2,500 women to prevent one death
from bleeding. If TXA was given within 1–3 hours of
delivery, the relative risk for death was 0.60 (as
opposed to more than 3 hours, which was 1.07 [not
significant]). There were no differences in medication-
related adverse events between the groups.
Bottom Line: Overall, although this study does pro-
vide a large, double blind RCT to look at the use of
TXA to prevent maternal death, it suffers from
a change in protocol in the middle of the study as well
as not being able to look at prevention of hysterec-
tomy as an outcome. Additionally, it was performed
in primarily low-resource settings and may not be
generalizable to all settings.
Comparing Success Rates of the Hayman
Compression Suture and the Bakri
Balloon Tamponade
This small retrospective comparison of two interven-
tions for postpartum hemorrhage compares the Hay-
man compression suture (modified B-Lynch) and
OBSTETRICS & GYNECOLOGY
Bakri balloon placement at the time of cesarean
delivery with postpartum hemorrhage. This is the
latest of a few small studies on this topic. The study
included patients in whom uterine artery ligation and
internal iliac artery ligation were undertaken after the
initial intervention. A total of 43 women underwent
Hayman suture, and 39 had a Bakri placement.
Overall, there was no significant difference in success
(prevention of hysterectomy) in either group before or
after internal iliac artery ligation, with suture success-
ful 76.7% of the time alone and 93% of the time with
internal iliac artery ligation; Bakri success rates were
74% and 87.2%, respectively. The authors note no
differences in estimated blood loss, length of hospi-
talization, or infection rates between the groups;
however, there was no long-term follow-up possible
to assess future fertility outcomes.
Bottom Line: The two interventions studied here are
equivalent in preventing hysterectomy in this small
series. At this point, a prospective RCT on this topic
would be most helpful.
Postpartum Blood Transfusion and Hemorrhage as
Independent Risk Factors for
Venous Thromboembolism
The linked Swedish birth and discharge registries
were used for this study, which assessed postpartum
hemorrhage and blood transfusion as independent
VOL. 0, NO. 0, MONTH 2018
Copyright Ó by American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
risk factors for postpartum venous thromboembolism
(VTE). In 82,376 deliveries, there were a total of 56
VTE cases documented. Overall, the risk of VTE
increased with the number of units of packed red
blood cells transfused, but there was no increased risk
with the transfusion of plasma (the number of women
transfused plasma was small, and the study was not
powered for this outcome) and no increased risk with
postpartum hemorrhage not requiring transfusion.
The overall VTE risk was lower than previously
reported (0.7/1,000 vs 1.3–1.7/1,000). The authors
also note a significantly increased risk of VTE in
women with preeclampsia and placental abruption
in their logistic regression final model. They hypoth-
esize that, in previous studies, the overall VTE risk is
higher owing to the inability to control for these
factors.
Bottom Line: Overall, postpartum hemorrhage was
not a risk factor for VTE, but transfusion for postpar-
tum hemorrhage was. Additional work needs to be
done looking at women with preeclampsia and pla-
cental abruption, because they may be at even higher
risk.
REFERENCE
1. World Health Organization. WHO recommendations for the
prevention and treatment of postpartum hemorrhage. Geneva
(Switzerland): World Health Organization; 2012.
Dunsmoor-Su What’s New in Postpartum Hemorrhage? 3