13% of maternal mortality in developed nations is attributed to postpartum hemorrhage (PPH) and 60-80% of the cases have been associated with suboptimal management.1 The incidence of major postpartum hemorrhage (>1500ml) reported each year is around 0.86-1.22%.2 It seems to be increasing and is possibly explained by an improving reporting and growing of caesarean section rates.2
- The postpartum hemorrhage treatment algorithm has to be dispensed to every person in the delivery ward and has to be accepted by them.
- Parallel to the infusion of oxytocin and then, if necessary, of sulprostone, the cause for the bleeding has to be determined by a clinical examination. Ultrasound can be helpful and is easily accessible.
- Avoid to underestimate the situation by a measured monitoring of the bleeding and a systematic documentation of the moment of each action realized.
- The good management of the postpartum hemorrhage depends on the correct organization of a multidisciplinary medical team.
the difficulties in the management of the PPH consist in the infrequent occurrence permitting an insufficient training of the different providers working in the delivery wards, but also are explained by insufficient interdisciplinary communication and confusion in the decision processes.
In September 2015, a working group composed from germanspeaking experts from Austria, Germany, and Switzerland has validated a simple algorithm to define the best pathway in the management of PPH.3 This algorithm is funded on the best evidence available and is the fruit of a multidisciplinary work assembling obstetricians, anesthesiologists and intensive care physicians.
In Switzerland the algorithm is supported by the Switzerland Society of Gynecology and Obstetrics, the German Society of Gynecology and Obstetrics, the Austrian Society of Gynecology and Obstetrics, the German Society of Anesthesiology and Intensive Medicine, the Society of Thrombosis and Haemostasis Research and the German Association of Midwives.4
Since 2012, every obstetrician can consult this expert guideline on https://www. sggg.ch/fileadmin/user_upload/Dokumente/ 3_Fachinformationen/1_Expertenbriefe/ Fr/26_Hemorragie_postpartum_ 2012. pdf.
What’s the content of this algorithm?
- Initiate the process for a vaginal bleeding more than 500ml after a vaginal birth or 1000ml after a cesarean section.
- 2 venous access lines are available and an individual is identified as responsible to infuse uterotonic drugs. According to the latest evidence, oxytocin is still the first choice. Carbetocin didn’t prove any superiority to oxytocin. Misoprostol is in this indication offlabel use and with no value added to oxytocin. A maximal duration of 30 minutes is accepted after a 30 minutes infusion of 40 U oxytocin to judge if the bleeding is under control or not.
- Measure in bags and weigh the blood losses to avoid underestimation and delayed treatment.
- The intervention process is clearly timed, the moment of each action is noted.
- A cervico-vaginal examination is completed by a uterine ultrasound exam. The aim is to determine the most prob able diagnosis causing the bleeding. More than 80% of the postpartum hemorrhage are attributed to uterine atony but other possible causes have to be considered (partial placental retention, disorders of placenta implantation, uterine inversion, uterine or cervical rupture, vaginal lacerations, …).
- An indwelling urinary catheter is installed and a person is designated to maintain an uterine massage.
- Call in the senior obstetrician and the anesthesiologist.
- Contact the blood bank to be ready to deliver blood products (freshfrozen plasma, platelets, fibrinogen and packed red blood cells).
- Transfer to an operating theatre.
- The anesthetist is present and starts the sulprostone infusion (up to 500μg during the first hour).
- As soon as the blood losses exceed 1500ml, start the infusion of 2g tranexamic acid and 24g of fibrinogen.
- Reconsider the different causes of PPH.
- Realize a manual uterine revision: this manipulation corrects a possible uterine inversion, controls the emptiness of the uterine cavity, and evaluates the uterine tonicity. The role of the curettage is questionable. It has been abandoned in many centers because it represents an invasive procedure creating a risk of uterine perforation, increases the decidual bleeding and promotes the formation of future adhesions.
- The optimal moment to proceed to infusion of red blood cells (RBC) and freshfrozen plasma (FFP) is still under debate. Some centers use an empirical procedure of massive transfusion of RBC and FFP with a ratio of 1 to 1 as soon as the bleeding is estimated superior to 1500ml. The infusion rate depends on the intensity of the bleeding and the stability of the patient. Other centers do research on a more rational use of blood products and propose the use of rotational thromboelastography (ROTEM).5, 6
- In case of a refractory uterine atony caused by uterotonic drugs (oxytocin, then sulprostone) an internal uterine compression is indicated. The Bakri balloon has been developed with this purpose and has a maximum volume inflated capacity of 500ml. The objectives of the balloon are to stabilize the patient and to ensure the possibility to consider other options in case it fails to stop the bleeding. The balloon creates a moment to correct the hemodynamics and the coagulation of the patient, to explore the possibility to access to an uterine embolization or to transfer the patient to another center with a better expertise. The transfer of the patient always requires hemodynamic stabilization.
- If the bleeding is stopped after the inflation of an intrauterine balloon, the patient can be transferred to an intermediateor highdependency care unit. The balloon is deflated after 1224 hours with a surgical or interventional radiologist ready to intervene if the bleeding restarts.
- This stage is the ultimate step rarely reached. The embolization of the uterine arteries implies a hemodynamic stability. Otherwise, the surgical abdominal opening is mandatory. According to surgical experience there are different options:
- compressions sutures (BLynch suture, Hayman stitch, Pereira stitch, Cho compression stitch)
- ligation of the uterine and/or hypogastric arteries
- ligation of the uteroovarian artery branches
- At this step the recombinant FVIIa infusion can be attempted if the platelets count is more than 50G/l and the fibrinogen more than 1g/l. Its use is offlabel with limited references of efficiency.7