Advances in the Treatment of Postpartum Hemorrhage

Alison M El Ayadi; Nuriya Robinson; Stacie Geller; Suellen Miller

Disclosures

Expert Rev of Obstet Gynecol. 2013;8(6):525-537. 

In This Article

Five-year View

Contemporary resuscitation approaches for PPH are not evidence-based, and recent research suggests that while volume resuscitation followed by RBC transfusion corrects hypovolemia, this approach worsens dilutional coagulopathy and enhances fibrinolysis, leading to poor patient outcomes. Trauma literature reports improved outcomes with increased FFP to RBC ratios, and research is underway to improve the evidence base for defining optimal blood transfusion protocols, particularly among the obstetric population. Mass transfusion protocols are beginning to be developed in the community hospital setting, which will improve treatment capacity and patient outcomes in these settings. Similarly, more rapid selection of blood products, normally a multi-hour process, is enabled by a greater capacity of point-of-care monitoring via thromboelastometry-based machines housed in the labor ward.

Randomized trials are currently ongoing around the administration and timing of fibrinogen concentrate, and the role of TXA for PPH. Results will be available within the next few years and will provide valuable guidance for including these agents in broad recommendations for treatment of PPH.

Greater attention is being paid to the development and implementation of low-cost health technologies to improve access to medical and first-aid devices in low-resource areas such as an IUB and the NASG, and low-technology blood pressure devices designed to trigger the process for referral by community health workers.

Medical education focusing on improving obstetrics and gynecology trainee knowledge and incorporating PPH teaching and drills into residency, nursing and midwifery curricula will improve provider and team preparedness for managing PPH. Greater use of obstetric warning systems and more precise identification of warning thresholds such as the shock index to trigger focused medical attention should expand across facilities. Similarly, evidence-based algorithms have recently been developed for risk prediction of PPH; there may be a future role for individualized medicine, including risk assessment and practice of anticipatory medicine in this field, though the evidence base is undeveloped.

Globally, task shifting for maternal health functions is necessary to improve broad access to lifesaving technologies. Emphasis on training to improve the capacity and effectiveness of non-clinicians and non-physician clinicians is crucial.

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