Comparative Effectiveness Review Number 151 Effective Health Care Program Management of Postpartum Hemorrhage Executive Summary Introduction Effective Health Care Program Postpartum hemorrhage (PPH) is The Effective Health Care Program commonly defined as blood loss exceeding was initiated in 2005 to provide valid 500 mL following vaginal birth and 1,000 evidence about the comparative mL following cesarean.1 Definitions effectiveness of different medical vary, however, and diagnosis of PPH is interventions. The object is to help subjective and often based on inaccurate consumers, health care providers, and estimates of blood loss.1-4 Moreover, others in making informed choices average blood loss at birth frequently among treatment alternatives. Through exceeds 500 or 1,000 mL,4 and symptoms its Comparative Effectiveness Reviews, of hemorrhage or shock from blood loss the program supports systematic may be hidden by the normal plasma appraisals of existing scientific volume increases that occur during evidence regarding treatments for pregnancy. PPH is often classified as high-priority health conditions. It primary/immediate/early, occurring within also promotes and generates new 24 hours of birth, or secondary/delayed/ scientific evidence by identifying gaps late, occurring from more than 24 hours in existing scientific evidence and postbirth to up to 12 weeks postpartum. In supporting new research. The program addition, PPH may be described as third puts special emphasis on translating or fourth stage depending on whether findings into a variety of useful it occurs before or after delivery of the formats for different stakeholders, placenta, respectively. Multiple studies including consumers. have noted an increase in PPH in high- resource countries, including the United The full report and this summary are States, Canada, Australia, Ireland, and available at www.effectivehealthcare. Norway, since the 1990s.5-9 ahrq.gov/reports/final.cfm. PPH is a leading cause of maternal mortality and morbidity worldwide, and Morbidity from PPH can be severe, accounts for nearly one-quarter of all with sequelae including organ failure, maternal pregnancy-related deaths.10 shock, edema, compartment syndrome, Multiple studies have suggested that transfusion complications, thrombosis, many deaths associated with PPH could acute respiratory distress syndrome, sepsis, be prevented with prompt recognition and anemia, intensive care, and prolonged more timely and aggressive treatment.11-13 hospitalization.14-16 Effective Health Care 1 The most common etiology of PPH is uterine atony interventions.24 Table 1 in the full report includes brief (impaired uterine contraction after birth), which occurs descriptions of interventions used in PPH management. in about 80 percent of cases. Atony may be related After PPH has been controlled, followup management to overdistention of the uterus, infection, placental 17 varies. It may include laboratory testing (e.g., hemoglobin abnormalities, or bladder distention. Although the and hematocrit), iron replacement therapy, and other majority of women who develop PPH have no identifiable interventions to assess and treat sequelae of PPH. risk factors, clinical factors associated with uterine atony, such as multiple gestation, polyhydramnios, high At a systems level, PPH has been the focus of perinatal parity, and prolonged labor, may lead to a higher index of care safety initiatives that attempt to improve patient suspicion.14,15,17,18 Other causes of PPH include retained outcomes by incorporating a variety of strategies, such placenta or clots, lacerations, uterine rupture or inversion, as practice guidelines or protocols, simulation drills, and and inherited or acquired coagulation abnormalities.17,18 teamwork training.25-29 These systems-level interventions may influence management of PPH. Interventions To Manage PPH Scope and Key Questions Organizations and associations including the World Health Organization, International Confederation of This systematic review provides a comprehensive review Midwives, International Federation of Gynecologists of potential benefits of PPH management (medical and and Obstetricians, American College of Obstetricians surgical), as well as harms associated with treatments in and Gynecologists, California Maternal Quality Care women with PPH. We assess intermediate outcomes, such Collaborative, and Royal College of Obstetricians as blood loss, hospital and intensive care unit (ICU) stay, and Gynaecologists have released guidelines for PPH and anemia, and longer term outcomes, including uterine prevention and management.10,15,17-21 Initial management preservation, fertility, breastfeeding, psychological impact includes identifying PPH, determining the cause, and and harms of treatment, and mortality related to treatment. implementing appropriate interventions based on the Key Questions etiology. We synthesized evidence in the published literature to Interventions to treat PPH generally proceed from less address the following Key Questions (KQs): to more invasive and include compression techniques, medications, procedures, and surgeries. PPH management KQ1. What is the evidence for the effectiveness of may also involve adjunctive therapies, such as blood and interventions for management of postpartum hemorrhage? 22,23 fluid replacement and/or an antishock garment, to a. What is the effectiveness of interventions intended to treat the blood loss and other sequelae that result from treat postpartum hemorrhage likely due to atony? PPH. PPH management varies significantly according to available resources. b. What is the effectiveness of interventions intended to treat postpartum hemorrhage likely due to retained Conservative management techniques, such as uterotonic placenta? medications, external uterine massage, and bimanual compression, are generally used as “first-line” treatments. c. What is the effectiveness of interventions intended to Procedures used in PPH management include manual treat postpartum hemorrhage likely due to genital tract removal of the placenta, manual removal of clots, uterine trauma? balloon tamponade, and uterine artery embolization.10,15,17,18 d. What is the effectiveness of interventions intended to Laceration repair is indicated when PPH is a result of treat postpartum hemorrhage likely due to uncommon genital tract trauma. causes (e.g., coagulopathies, uterine inversion, Surgical options when other measures fail to control subinvolution, abnormal placentation)? bleeding include curettage, uterine and other pelvic KQ2. What is the evidence for choosing one intervention artery ligation, uterine compression sutures, and over another and when to proceed to subsequent hysterectomy.10,15,17,18 More invasive procedures interventions for management of postpartum hemorrhage? (e.g., uterine balloon tamponade and uterine artery embolization) and surgical techniques are generally KQ3. What are the harms, including adverse events, used after first-line conservative management has failed associated with interventions for management of to control bleeding and can be considered second-line postpartum hemorrhage? 2 KQ4. What is the effectiveness of interventions to treat depicts the KQs within the context of the population, acute blood loss anemia after stabilization of postpartum intervention, comparator, outcomes, timing, and setting hemorrhage? (PICOTS) parameters described in the review. In KQ5. What systems-level interventions are effective in general, the figure illustrates how interventions such improving management of postpartum hemorrhage? as compression techniques, medications, procedures, surgeries, blood and fluid products, antishock garments, Analytic Framework or systems-level interventions may result in intermediate outcomes such as blood loss, transfusion, ICU admission, The analytic framework illustrates the population, anemia, or length of stay and/or in final health outcomes interventions, and outcomes that guided the literature such as mortality, uterine preservation, future fertility, search and synthesis (Figure A). The framework for breastfeeding, or psychological impact. Also, adverse management of PPH includes women with PPH from events may occur at any point after the intervention is immediately postbirth to 12 weeks postpartum following received. pregnancy of at least 24 weeks’ gestation. The figure Figure A. Analytic framework Sytems-level interventions (KQ5 Interventions Interventions for acute • Compression techniques blood loss anemia • Medications • Procedures • Surgeries • Blood and fluid products • Antishock garment (KQ4) Final health Management Intermediate outcomes outcomes of Postpartum Hemorrhage (PPH) • Blood loss • Mortality (KQ1) (KQ2) Woimen with PPH • Transfusion • Uterine from immediately • ICU admission preservation postbirth to 12 • Anemia • Future fertility weeks postpartum • Length of stay • Breastfeeding following pregnancy • Psychological impact of > 24 weeks (KQ3) gestation • Resolution of anemia Harms • Harms of treatment ICU = intensive care unit; KQ = Key Question. 3 Methods However, the limited availability of skilled clinicians and treatment options in many of these countries results in Literature Search Strategy different standards of care and clinical approaches from A librarian employed search strategies, provided in those in the United States. Appendix A of the full report, to retrieve research on PPH is a complex condition. Treatments are selected interventions for PPH. We searched MEDLINE® via the not