ACOG Updates Recommendations on Postpartum Hemorrhage

Troy Brown, RN

September 25, 2017

Updated recommendations on postpartum hemorrhage were released by the American College of Obstetricians and Gynecologists (ACOG). The updated practice bulletin expands on previous guidance to include recommendations for standard, hospital-wide protocols and potential treatments.

ACOG's Committee on Practice Bulletins–Obstetrics, in collaboration with Laurence E. Shields, MD; Dena Goffman, MD; and Aaron B. Caughey, MD, PhD, published the updated practice bulletin online September 21 and in the October issue of Obstetrics & Gynecology. It replaces the practice bulletin published in October 2006.

"Because obstetric hemorrhage is unpredictable, relatively common, and leads to severe morbidity and mortality, all obstetric unit members, including the physicians, midwives, and nurses who provide obstetric care, should be prepared to manage women who experience it," the authors write.

"By implementing standard protocols, we can improve outcomes," Aaron Caughey, MD, PhD, coauthor of the practice bulletin and professor and chair of Obstetrics and Gynecology at Oregon Health & Science University in Portland, said in a news release. "And this is even more critical for rural hospitals that often do not have the ability to treat a woman who may need a massive blood transfusion. They need to have a response plan in place for these obstetric emergencies, which includes triage and transferring patients to higher-level facilities, if necessary."

"One of the most important things is for us not to underappreciate the real risk of maternal hemorrhage, and to take advantage of the systematic approach and toolkits which are now available, such as the [California Maternal Quality Care Collaborative) hemorrhage quality improvement toolkit," James Byrne, MD, chair of the Department of Ob-Gyn, Santa Clara Valley Medical Center, San Jose, and affiliated clinical professor at Stanford University School of Medicine, California, told Medscape Medical News.

"This is so important to have team readiness to identify women with risk factors for bleeding and monitor those risk factors while the woman's in labor, and then be able to act earlier and more efficiently if hemorrhage begins to occur. Team readiness could be helped with emergency drills, and particularly working with their hospital to put in place maneuvers such as massive transfusion protocols and working out all the logistical gaps prior to needing to use those in a real-life setting," Dr Byrne explained.

According to the new recommendations, three components for active management of the third stage of labor can help reduce the incidence of postpartum hemorrhage: oxytocin administration, uterine massage, and umbilical cord traction.

In the case postpartum hemorrhage is caused by uterine atony, uterotonics, which induce contraction of the uterus, should be first-line treatment.

When uterotonic agents fail to control postpartum bleeding, treatment should be escalated to include measures such as intrauterine balloons and tranexamic acid. Tranexamic acid stops blood clots from breaking down and can be given when initial treatments fail; research has found it reduces mortality when administered within 3 hours after birth.

"Less invasive methods should always be used first," Dr Caughey said in the news release. "If those methods fail, then more aggressive interventions must be considered to preserve the life of the mother."

Measured, Not Estimated, Blood Loss

ACOG defines postpartum hemorrhage as cumulative blood loss equal to 1000 mL or more along with signs or symptoms of hypovolemia within 24 hours after delivery (including intrapartum loss), regardless of route of delivery. Nevertheless, "a blood loss greater than 500 mL in a vaginal delivery should be considered abnormal and should serve as an indication for the health care provider to investigate the increased blood deficit," the authors write.

"There's been a significant shift, moving away from estimated blood loss to measured blood loss for obstetrical cases," Dr Byrne told Medscape Medical News. "There are a few different methods to measure blood loss; some of them involve weighing materials and using graduated cylinders. There's also some new technology and apps which have been developed to measure the saturation of blood loss in surgical sponges. Moving from historic estimated blood loss to actually measuring blood loss is a very important part of providing safer care," he said.

When bleeding in the immediate postpartum period exceeds 500 mL in a vaginal delivery or 1000 mL in a cesarean delivery, the clinician should conduct a thorough evaluation. "A rapid physical examination of the uterus, cervix, vagina, vulva, and perineum can often identify the etiology (sometimes multiple sources) of the postpartum hemorrhage. Obstetrician–gynecologists and other obstetric care providers should be familiar with algorithms for the diagnosis and management of postpartum hemorrhage and, ideally, these should be posted on labor and delivery units," the authors explain.

Signs, Symptoms May Not Appear Until Substantial Blood Loss Has Occurred

Primary postpartum hemorrhage occurs within the first 24 hours after birth. Causes include uterine atony, lacerations, retained placenta, abnormally adherent placenta (accreta), defects of coagulation (eg, disseminated intravascular coagulation), and uterine inversion.

Secondary postpartum hemorrhage occurs more than 24 hours and up to 12 weeks after delivery. Causes include subinvolution of the placental site, retained products of conception, infection, and inherited coagulation defects (eg, factor deficiency such as von Willebrand).

In the past, a drop in hematocrit of 10% had been suggested as an alternative marker for postpartum hemorrhage; "however, determinations of hemoglobin or hematocrit concentrations are often delayed, may not reflect current hematologic status, and are not clinically useful in the setting of acute postpartum hemorrhage," the authors write.

In addition, signs and symptoms of significant blood loss often do not appear in postpartum women until substantial blood loss has occurred. For this reason, if a patient has tachycardia and hypotension, the clinician should suspect "considerable blood loss, usually representing 25% of the woman's total blood volume (or approximately 1,500 mL or more), has occurred," they warn.

"In women with ongoing bleeding that equates to the blood loss of 1,500 mL or more or in women with abnormal vital signs (tachycardia and hypotension), immediate preparation for transfusion should be made. Because such a large blood loss includes depletion of coagulation factors, it is common for such patients to develop a consumptive coagulopathy, commonly labeled as disseminated intravascular coagulation, and the patients will require platelets and coagulation factors in addition to packed red blood cells," the authors continue.

"Findings of critically low fibrinogen should be particularly anticipated in the setting of placental abruption or amniotic fluid embolism, and early use of cryoprecipitate is commonly included as part of the resuscitation," they add.

Laboratory Services, Blood Banks Have Important Roles

"The hospital administration and laboratory services really need to step up and become stakeholders in helping with these outcomes. That might help some of the [physicians] get a little more buy-in from their hospitals, compared to in the past, when maybe [obstetric] hemorrhage wasn't recognized as important as, say, the thoracic surgery cases going on," Dr Byrne said.

"Maternal hemorrhage and maternal morbidity have been added to some of the national quality indicators, so now hospitals are going to be reporting their performance on this, and since hemorrhage is a relatively rare event, they really need to invest in the systems approach, training their staff and working on the logistics with their blood banks and lab services to be able to do it in the best modern manner possible," he added.

The authors and Dr Byrne have disclosed no relevant financial relationships.

Obstet Gynecol. 2017;130:923-925. Abstract

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