• American College of Obstetricians and Gynecologists (ACOG). Postpartum hemorrhage. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2006 Oct. 10 p. (ACOG practice bulletin; no. 76). [40 references]

This is the current release of the guideline.

Postpartum hemorrhage

Evaluation
Management
Treatment

Emergency Medicine
Family Practice
Obstetrics and Gynecology

Physicians

• To aid practitioners in making decisions about appropriate obstetric and gynecologic care
• To review the etiology, evaluation, and management of postpartum hemorrhage

• Women during the first 24 hours after delivery (at risk for primary postpartum hemorrhage), especially those with:
  • Uterine atony
  • Retained placenta—especially placenta accreta
  • Defects in coagulation
  • Uterine inversion
• Women between 24 hours and 6–12 weeks after delivery (at risk for secondary postpartum hemorrhage),especially those with:
  • Subinvolution of placental site
  • Retained products of conception
  • Infection
  • Inherited coagulation defects
• Women with other risk factors for postpartum hemorrhage

Evaluation/Management

1. Multi-disciplinary approach with high clinical suspicion
2. Laboratory evaluation of lost blood
3. Testing for bleeding disorders among patients with menorrhagia
4. Medical management, including use of uterotonic agents
5. Exploratory laparotomy
6. Ultrasonography
7. Drainage of hematomas
8. Uterine compression or massage
9. Tamponade: packing of the uterine cavity, Foley catheter insertion, Sengstaken-Blakemore tube insertion, SOS Bakri tamponade balloon use
10. Surgical management, including uterine curettage and hysterectomy
11. Arterial ligation or embolization
12. Blood component therapy (donor or autologous): packed red cells, platelets, fresh frozen plasma, cryoprecipitate
13. Manual replacement of the uterine corpus
14. Antibiotics

Poststabilization Management

1. Prenatal vitamin and mineral capsules
2. Additional iron tablets
3. Erythropoietin

• Time to cessation of bleeding
• Incidence of serious sequelae (adult respiratory distress syndrome, coagulopathy, shock, loss of fertility, and pituitary necrosis)
• Loss of fertility
• Mortality

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

The MEDLINE database, the Cochrane Library, and the American College of Obstetricians and Gynecologists' own internal resources and documents were used to conduct a literature search to locate relevant articles published between January 1901 and June 2006. The search was restricted to articles published in the English language. Priority was given to articles reporting results of original research, although review articles and commentaries also were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion in this document. Guidelines published by organizations or institutions such as the National Institutes of Health and American College of Obstetricians and Gynecologists were reviewed, and additional studies were located by reviewing bibliographies of identified articles.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Studies were reviewed and evaluated for quality according to the method outlined by the U.S. Preventive Services Task Force:

I: Evidence obtained from at least one properly designed randomized controlled trial.

II-1: Evidence obtained from well-designed controlled trials without randomization.

II-2: Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.

II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Systematic Review

Not stated

Expert Consensus

Analysis of available evidence was given priority in formulating recommendations. When reliable research was not available, expert opinions from obstetrician–gynecologists were used. See also the "Rating Scheme for the Strength of Recommendations" field regarding Grade C recommendations.

Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories:

Level A — Recommendations are based on good and consistent scientific evidence.

Level B — Recommendations are based on limited or inconsistent scientific evidence.

Level C — Recommendations are based primarily on consensus and expert opinion.

A formal cost analysis was not performed and published cost analyses were not reviewed.

Internal Peer Review

Practice Bulletins are validated by two internal clinical review panels composed of practicing obstetrician-gynecologists generalists and sub-specialists. The final guidelines are also reviewed and approved by the American College of Obstetricians and Gynecologists (ACOG) Executive Board.

The grades of evidence (I-III) and levels of recommendations (A-C) are defined at the end of the "Major Recommendations" field.

The following recommendations and conclusions are based primarily on consensus and expert opinion (Level C):

• Uterotonic agents should be the first-line treatment for postpartum hemorrhage due to uterine atony.
• Management may vary greatly among patients, depending on etiology and available treatment options, and often a multidisciplinary approach is required.
• When uterotonics fail following vaginal delivery, exploratory laparotomy is the next step.
• In the presence of conditions known to be associated with placenta accreta, the obstetric care provider must have a high clinical suspicion and take appropriate precautions.

Definitions:

Grades of Evidence

I: Evidence obtained from at least one properly designed randomized controlled trial.

II-1: Evidence obtained from well-designed controlled trials without randomization.

II-2: Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.

II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Levels of Recommendations

Level A — Recommendations are based on good and consistent scientific evidence.

Level B — Recommendations are based on limited or inconsistent scientific evidence.

Level C — Recommendations are based primarily on consensus and expert opinion.

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Appropriate evaluation and management of women with postpartum hemorrhage

• Undiluted rapid oxytocin IV infusion causes hypotension.
• Care must be taken in performing curettage to avoid perforation of the uterus.

• Relative contraindication for 15-methylprostaglandin F_2a in patients with hepatic, renal, and cardiac disease. Diarrhea, fever, tachycardia can occur.
• Avoid methylergonovine if patient is hypertensive.
• Avoid 15-methylprostaglandin F_2a in asthmatic patients.
• Avoid dinoprostone if patient is hypotensive. Fever is common.

These guidelines should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.

An implementation strategy was not provided.

Getting Better

Effectiveness
Timeliness

• American College of Obstetricians and Gynecologists (ACOG). Postpartum hemorrhage. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2006 Oct. 10 p. (ACOG practice bulletin; no. 76). [40 references]

Not applicable: The guideline was not adapted from another source.

2006 Oct

American College of Obstetricians and Gynecologists - Medical Specialty Society

American College of Obstetricians and Gynecologists (ACOG)

American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins-Obstetrics

Not stated

Not stated

This is the current release of the guideline.

Proposed performance measures are included in the original guideline document.

None available

This NGC summary was completed by ECRI Institute on August 2, 2007. The information was verified by the guideline developer on September 10, 2007. This summary was updated by ECRI Institute on March 21, 2008 following the FDA advisory on Erythropoiesis Stimulating Agents. This summary was updated by ECRI Institute on August 15, 2008 following the U.S. Food and Drug Administration advisory on Erythropoiesis Stimulating Agents (ESAs).

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.