Postpartum haemorrhage (PPH) remains the leading cause of pregnancy-related deaths worldwide. Typically, bleeding is controlled by timely obstetric measures in parallel with resuscitation and treatment of coagulopathy. Early recognition of abnormal coagulation is crucial and haemostatic support should be considered simultaneously with other strategies as coagulopathies contribute to the progression to massive haemorrhage. However, there is lack of agreement on important topics in the current guidelines for management of PPH. A clinical definition of PPH is paramount to understand the situation to which the treatment recommendations relate; however, reaching a consensus has previously proven difficult. Traditional definitions are based on volume of blood loss, which is difficult to monitor, can be misleading and leads to treatment delay. A multidisciplinary approach to define PPH considering vital signs, clinical symptoms, coagulation and haemodynamic changes is needed. Moreover, standardised algorithms or massive haemorrhage protocols should be developed to reduce the risk of morbidity and mortality and improve overall clinical outcomes in PPH. If available, point-of-care testing should be used to guide goal-directed haemostatic treatment. Tranexamic acid should be administered as soon as abnormal bleeding is recognised. Fibrinogen concentrate rather than fresh frozen plasma should be administered to restore haemostasis where there is elevated risk of fibrinogen deficiency (e.g., in catastrophic bleeding or in cases of abruption or amniotic fluid embolism) as it is a more concentrated source of fibrinogen. Lastly, organisational considerations are equally as important as clinical interventions in the management of PPH and have the potential to improve patient outcomes.

From the Department of Anaesthesiology Westpfalz Klinikum Kaiserslautern Germany

Zobrazit více v PubMed

World Health Organization. WHO Recommendations for the Prevention and Treatment of Postpartum Haemorrhage. Geneva, Switzerland: World Health Organization; 2012. Available from: https://apps.who.int/iris/bitstream/handle/10665/75411/9789241548502_eng.pdf [Accessed 31 May 2022].

Say L, Chou D, Gemmill A, et al. . Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health 2014; 2:e323–e333. PubMed

Kassebaum NJ, Barber RM, Bhutta ZA, et al. . Global, regional, and national levels of maternal mortality, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016; 388:1775–1812. PubMed PMC

Knight M, Callaghan WM, Berg C, et al. . Trends in postpartum hemorrhage in high resource countries: a review and recommendations from the International Postpartum Hemorrhage Collaborative Group. BMC Pregnancy Childbirth 2009; 9:55. PubMed PMC

Ford JB, Patterson JA, Seeho SKM, Roberts CL. Trends and outcomes of postpartum haemorrhage, 2003–2011. BMC Pregnancy Childbirth 2015; 15:334. PubMed PMC

MBRRACE-UK. Saving Lives, Improving Mothers’ Care. Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2017-19 2021. Available from: https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/maternal-report-2021/MBRRACE-UK_Maternal_Report_2021_-_FINAL_-_WEB_VERSION.pdf. [Accessed 31 May 2022].

Calvert C, Thomas SL, Ronsmans C, et al. . Identifying regional variation in the prevalence of postpartum haemorrhage: a systematic review and meta-analysis. PLoS One 2012; 7:e41114. PubMed PMC

Evensen A, Anderson JM, Fontaine P. Postpartum hemorrhage: prevention and treatment. Am Fam Physician 2017; 95:442–449. PubMed

Wormer KC JR, Bryant SB. Acute postpartum hemorrhage. [Updated 2020 Nov 30]. In: StatPearls, [Internet]., Treasure Island (FL): StatPearls Publishing, 2021, Jan-., Available from:, https://www.ncbi.nlm.nih.gov/books/NBK499988/. [Accessed 31 May 2022].

ACOG. Practice Bulletin No. 183: postpartum hemorrhage. Obstet Gynecol 2017; 130:e168–e186. PubMed

Begley CM, Gyte GML, Devane D, et al. . Active versus expectant management for women in the third stage of labour. Cochrane Database Syst Rev 2011; 2: CD007412-CD. PubMed PMC

Knight M, Bunch K, Tuffnell D, Shakespeare J, Kotnis R, Kenyon S, et al. Saving lives, improving mothers’ care: Lessons learned to inform maternity care from the UK and Ireland confidential enquiries into maternal deaths and morbidity 2016-18. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2020: p36-42.; 2019.

Rollins MD, Rosen MA. Gleason CA, Juul SE. 16 - Obstetric analgesia and anesthesia. Avery's Diseases of the Newborn (Tenth Edition). Philadelphia: Elsevier; 2018. 170–179.

Cerneca F, Ricci G, Simeone R, et al. . Coagulation and fibrinolysis changes in normal pregnancy. Increased levels of procoagulants and reduced levels of inhibitors during pregnancy induce a hypercoagulable state, combined with a reactive fibrinolysis. Eur J Obstet Gynecol Reprod Biol 1997; 73:31–36. PubMed

Stirling Y, Woolf L, North WR, et al. . Haemostasis in normal pregnancy. Thromb Haemost 1984; 52:176–182. PubMed

Bremme KA. Haemostatic changes in pregnancy. Best Pract Res Clin Haematol 2003; 16:153–168. PubMed

Gill P, Patel A, Van Hook J. Uterine atony. [Updated 2020 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493238/ [Accessed 12 May 2022].

Mousa HA, Blum J, Abou El Senoun G, et al. . Treatment for primary postpartum haemorrhage. Cochrane Database Syst Rev 2014; 2014:Cd003249. PubMed PMC

Liu C-N, Yu F-B, Xu Y-Z, et al. . Prevalence and risk factors of severe postpartum hemorrhage: a retrospective cohort study. BMC Pregnancy Childbirth 2021; 21:332. PubMed PMC

Nyfløt LT, Sandven I, Stray-Pedersen B, et al. . Risk factors for severe postpartum hemorrhage: a case-control study. BMC Pregnancy Childbirth 2017; 17:17. PubMed PMC

Nakagawa K, Yamada T, Cho K. Independent risk factors for postpartum haemorrhage. Crit Care Obst Gyne 2016; 2:1–7.

Wiegand SL, Beamon CJ, Chescheir NC, Stamilio D. Idiopathic polyhydramnios: severity and perinatal morbidity. Am J Perinatol 2016; 33:658–664. PubMed

Arcudi SRA, Ossola MW, Iurlaro E, et al. . Assessment of postpartum haemorrhage risk among women with thrombocytopenia: a cohort study [abstract]. Res Pract Thromb Haemost 2020; 4:482–488. PubMed

Nyfløt LT, Stray-Pedersen B, Forsén L, Vangen S. Duration of labor and the risk of severe postpartum hemorrhage: a case-control study. PLoS One 2017; 12:e0175306. PubMed PMC

Kramer MS, Dahhou M, Vallerand D, et al. . Risk Factors for Postpartum Hemorrhage: Can We Explain the Recent Temporal Increase? J Obstet Gynaecol Can 2011; 33:810–819. PubMed

Buzaglo N, Harlev A, Sergienko R, Sheiner E. Risk factors for early postpartum hemorrhage (PPH) in the first vaginal delivery, and obstetrical outcomes in subsequent pregnancy. J Matern Fetal Neonatal Med 2015; 28:932–937. PubMed

Majluf-Cruz K, Anguiano-Robledo L, Calzada-Mendoza CC, et al. . von Willebrand Disease and other hereditary haemostatic factor deficiencies in women with a history of postpartum haemorrhage. Haemophilia 2020; 26:97–105. PubMed

Main EK, Goffman D, Scavone BM, et al. . National partnership for maternal safety: consensus bundle on obstetric hemorrhage. Obstet Gynecol 2015; 126:155–162. PubMed

Anderson JM, Etches D. Prevention and management of postpartum hemorrhage. Am Fam Physician 2007; 75:875–882. PubMed

Collis RE, Collins PW. Haemostatic management of obstetric haemorrhage. Anaesthesia 2015; 70: (Suppl 1): 78–86. e27-8. PubMed

Charbit B, Mandelbrot L, Samain E, et al. . The decrease of fibrinogen is an early predictor of the severity of postpartum hemorrhage. J Thromb Haemost 2007; 5:266–273. PubMed

Collins PW, Lilley G, Bruynseels D, et al. . Fibrin-based clot formation as an early and rapid biomarker for progression of postpartum hemorrhage: a prospective study. Blood 2014; 124:1727–1736. PubMed

Wikkelsø AJ, Edwards HM, Afshari A, et al. . Preemptive treatment with fibrinogen concentrate for postpartum haemorrhage: randomized controlled trial. Br J Anaesth 2015; 114:623–633. PubMed

Collins P, Abdul-Kadir R, Thachil J. Management of coagulopathy associated with postpartum hemorrhage: guidance from the SSC of the ISTH. J Thromb Haemost 2016; 14:205–210. PubMed

Erez O. Disseminated intravascular coagulation in pregnancy: New insights. Thrombosis Update 2021; 6:100083.

Thachil J, Toh CH. Disseminated intravascular coagulation in obstetric disorders and its acute haematological management. Blood Rev 2009; 23:167–176. PubMed

Abdul-Kadir R, McLintock C, Ducloy A-S, et al. . Evaluation and management of postpartum hemorrhage: consensus from an international expert panel. Transfusion 2014; 54:1756–1768. PubMed

Sentilhes L, Goffinet F, Vayssière C, Deneux-Tharaux C. Comparison of postpartum haemorrhage guidelines: discrepancies underline our lack of knowledge. BJOG 2017; 124:718–722. PubMed

Muñoz M, Stensballe J, Ducloy-Bouthors AS, et al. . Patient blood management in obstetrics: prevention and treatment of postpartum haemorrhage. A NATA consensus statement. Blood Transfus 2019; 17:112–136. PubMed PMC

Diaz V, Abalos E, Carroli G. Methods for blood loss estimation after vaginal birth. Cochrane Database Syst Rev 2018; 9:Cd010980. PubMed PMC

Pacagnella RC, Souza JP, Durocher J, et al. . A systematic review of the relationship between blood loss and clinical signs. PLoS One 2013; 8:e57594. PubMed PMC

de Lloyd L, Bovington R, Kaye A, et al. . Standard haemostatic tests following major obstetric haemorrhage. Int J Obstet Anesth 2011; 20:135–141. PubMed

Cortet M, Deneux-Tharaux C, Dupont C, et al. . Association between fibrinogen level and severity of postpartum haemorrhage: secondary analysis of a prospective trial. Br J Anaesth 2012; 108:984–989. PubMed

Hiippala ST, Myllylä GJ, Vahtera EM. Hemostatic factors and replacement of major blood loss with plasma-poor red cell concentrates. Anesth Analg 1995; 81:360–365. PubMed

Collins PW, Cannings-John R, Bruynseels D, et al. . Viscoelastometric-guided early fibrinogen concentrate replacement during postpartum haemorrhage: OBS2, a double-blind randomized controlled trial. Br J Anaesth 2017; 119:411–421. PubMed

Gonzalez E, Moore EE, Moore HB, et al. . Goal-directed hemostatic resuscitation of trauma-induced coagulopathy: a pragmatic randomized clinical trial comparing a viscoelastic assay to conventional coagulation assays. Ann Surg 2016; 263:1051–1059. PubMed PMC

Solomon C, Collis RE, Collins PW. Haemostatic monitoring during postpartum haemorrhage and implications for management. Br J Anaesth 2012; 109:851–863. PubMed PMC

Bell SF, Roberts TCD, Freyer Martins Pereira J, et al. . The sensitivity and specificity of rotational thromboelastometry (ROTEM) to detect coagulopathy during moderate and severe postpartum haemorrhage: a prospective observational study. Int J Obstet Anesth 2022; 49:103238. PubMed

Roberts TCD, De Lloyd L, Bell SF, et al. . Utility of viscoelastography with TEG 6 s to direct management of haemostasis during obstetric haemorrhage: a prospective observational study. Int J Obstet Anesth 2021; 47:103192. PubMed

Dodge LE, Carterson AJ, Hacker MR, et al. . Antepartum fibrinogen concentration as a predictor of bleeding complications. J Matern Fetal Neonatal Med 2021; 34:3586–3590. PubMed

Karlsson O, Jeppsson A, Thornemo M, et al. . Fibrinogen plasma concentration before delivery is not associated with postpartum haemorrhage: a prospective observational study. Br J Anaesth 2015; 115:99–104. PubMed

Peyvandi F, Biguzzi E, Franchi F, et al. . Elevated prepartum fibrinogen levels are not associated with a reduced risk of postpartum hemorrhage. J Thromb Haemost 2012; 10:1451–1453. PubMed

McCormack PL. Tranexamic acid: a review of its use in the treatment of hyperfibrinolysis. Drugs 2012; 72:585–617. PubMed

WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with postpartum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet 2017; 389:2105–2116. PubMed PMC

Alam A, Choi S. Prophylactic use of tranexamic acid for postpartum bleeding outcomes: A systematic review and meta-analysis of randomized controlled trials. Transfus Med Rev 2015; 29:231–241. PubMed

Sentilhes L, Sénat MV, Le Lous M, et al. . Tranexamic acid for the prevention of blood loss after cesarean delivery. N Engl J Med 2021; 384:1623–1634. PubMed

Sentilhes L, Winer N, Azria E, et al. . Tranexamic acid for the prevention of blood loss after vaginal delivery. N Engl J Med 2018; 379:731–742. PubMed

Collins PW, Solomon C, Sutor K, et al. . Theoretical modelling of fibrinogen supplementation with therapeutic plasma, cryoprecipitate, or fibrinogen concentrate. Br J Anaesth 2014; 113:585–595. PubMed PMC

Ahmed S, Harrity C, Johnson S, et al. . The efficacy of fibrinogen concentrate compared with cryoprecipitate in major obstetric haemorrhage – an observational study. Transfus Med 2012; 22:344–349. PubMed

Green L, Bolton-Maggs P, Beattie C, et al. . British Society of Haematology Guidelines on the spectrum of fresh frozen plasma and cryoprecipitate products: their handling and use in various patient groups in the absence of major bleeding. Br J Haematol 2018; 181:54–67. PubMed

Zaidi A, Kohli R, Daru J, et al. . Early use of fibrinogen replacement therapy in postpartum hemorrhage-a systematic review. Transfus Med Rev 2020; 34:101–107. PubMed

Ducloy-Bouthors A, Mercier F, Grouin J, et al. . Early and systematic administration of fibrinogen concentrate in postpartum haemorrhage following vaginal delivery: the FIDEL randomised controlled trial. BJOG 2021; 128:1814–1823. PubMed

Green L, Daru J, Dodds J, et al. . Effect of early cryoprecipitate transfusion versus standard care in women who develop severe postpartum haemorrhage (ACROBAT) in the UK: a protocol for a pilot cluster randomised trial. BMJ Open 2020; 10:e036416. PubMed PMC

Green L, Daru J, Gonzalez Carreras FJ, et al. . Early cryoprecipitate transfusion versus standard care in severe postpartum haemorrhage: a pilot cluster-randomised trial. Anaesthesia 2022; 77:175–184. PubMed PMC

Kamidani R, Miyake T, Okada H, et al. . Effect of cryoprecipitate transfusion therapy in patients with postpartum hemorrhage: a retrospective cohort study. Sci Rep 2021; 11:18458. PubMed PMC

Novo Nordisk. NovoSeven® recommended for approval for the treatment of severe postpartum haemorrhage by the European Medicines Agency [press release]. 2022. Available from: https://ml-eu.globenewswire.com/Resource/Download/552aad78-3aae-4cb4-8570-f8b3ac391058.

Van de Velde M, Diez C, Varon AJ. Obstetric hemorrhage. Curr Opin Anaesthesiol 2015; 28:186–190. PubMed

Ducloy-Bouthors A-S, Ducloy J-C, Sicot J. Impact of a perinatal network medical practice improvement program on postpartum hemorrhage-related morbidity. Int J Gynecol Obstet 2009; 104:68–69. PubMed

Bell SF, Collis RE, Pallmann P, et al. . Reduction in massive postpartum haemorrhage and red blood cell transfusion during a national quality improvement project, Obstetric Bleeding Strategy for Wales, OBS Cymru: an observational study. BMC Pregnancy Childbirth 2021; 21:377. PubMed PMC

Snegovskikh D, Souza D, Walton Z, et al. . Point-of-care viscoelastic testing improves the outcome of pregnancies complicated by severe postpartum hemorrhage. J Clin Anesth 2018; 44:50–56. PubMed

McNamara H, Kenyon C, Smith R, et al. . Four years’ experience of a ROTEM (®) -guided algorithm for treatment of coagulopathy in obstetric haemorrhage. Anaesthesia 2019; 74:984–991. PubMed

Longstaff C. Measuring fibrinolysis: from research to routine diagnostic assays. J Thromb Haemost 2018; 16:652–662. PubMed PMC

Murao S, Nakata H, Roberts I, Yamakawa K. Effect of tranexamic acid on thrombotic events and seizures in bleeding patients: a systematic review and meta-analysis. Crit Care 2021; 25:380. PubMed PMC

Idialisoa R, Jouffroy R, Philippe P, et al. . Beware of using tranexamic acid in parturients with eclampsia. Anaesth Crit Care Pain Med 2016; 35:231–232. PubMed

Karlsson O, Jeppsson A, Hellgren M. Factor XIII activity at onset of labour and association with postpartum haemorrhage: an exploratory posthoc study. Int J Obstet Anesth 2021; 47:103174. PubMed

Bedreli S, Sowa J-P, Malek S, et al. . Rotational thromboelastometry can detect factor XIII deficiency and bleeding diathesis in patients with cirrhosis. Liver Int 2017; 37:562–568. PubMed

Raspé C, Besch M, Charitos EI, et al. . Rotational thromboelastometry for assessing bleeding complications and factor XIII deficiency in cardiac surgery patients. Clin Appl Thromb Hemost 2018; 24:136S–144S. PubMed PMC

Cooper N, O’Brien S, Siassakos D. Training health workers to prevent and manage postpartum haemorrhage (PPH). Best Pract Res Clin Obstet Gynaecol 2019; 61:121–129. PubMed

Crofts JF, Ellis D, Draycott TJ, et al. . Change in knowledge of midwives and obstetricians following obstetric emergency training: a randomised controlled trial of local hospital, simulation centre and teamwork training. BJOG 2007; 114:1534–1541. PubMed