The American
College of Obstetricians and Gynecologists (ACOG) recently released expanded guidelines
for management of postpartum hemorrhage (PPH)—the leading cause of maternal
mortality worldwide.
PPH is
defined as total blood loss of 1000 ml or more along with signs or symptoms of
hypovolemia within 24 hours after the labor, but can occur up to 12 weeks
postpartum. Although Maternal Mortality Rates(MMR) have decreased worldwide in
last 4 decades, it still accounts for 10% of all pregnancy related mortality.
Incidence
varies, but 1-5% is reasonable estimate, with uterine atony accounting for
70-80% of cases PPH.
This
practice bulletin discusses the risk factors along with evaluation, prevention,
and management of maternal hemorrhage.
It also
calls upon all obstetricians and other obstetric care providers to formulate
standard protocols for recognizing, evaluating and management of maternal
hemorrhage by multidisciplinary approach and implement it in every center.
Multidisciplinary
teams, including physicians, nurses and midwives, should be trained to
implement key elements in four categories, including readiness to respond;
recognition and prevention measures; multidisciplinary response; and data
reporting and systematic learning, including drills like simulation-based
training.
ACOG also
has partnered with multiple organization to implement the care bundle suggested
by Alliance for Innovation on Maternal Health (AIM),
which many states have are already adapted.
It also lays
emphasis on identifying the patients at risk of developing PPH, prenatally, during
admission and during labor. It includes patients with vaginal lacerations,
retained placenta, abnormally adherent placenta with previous cesarean section.
All Ob-gyn should be aware of high risk of PPH in placenta previa with previous
uterine scar.
Uterotonic
agents should be the first line of treatment in case of atonic PPH, choice of a
specific agent is at the discretion of the provider as none is identified as
superior over other. Active management of third stage of labor should be
implemented.
All
hospitals, especially those in rural areas should be able to escalate the
efforts quickly, and have a specific plan to go to next level of treatment or
quickly refer patient to a specialty hospital.
Tranexamic
acid can be given when primary line of therapy fails, it is especially found
effective if given within 3 hours of birth.
Surgical
approach includes Intrauterine balloon tamponade, but less invasive methods
should always be used first.
All
hospitals should have functioning massive transfusion protocols and ‘hemorrhage
carts’, with all the necessary medication in place.
The Practice Bulletin #183, "Postpartum Hemorrhage" is published in October issue
of Obstetrics and Gynecology.
ACOG press release
