Guidelines Summary

FIGO guidelines

The International Federation of Gynecology and Obstetrics (FIGO) has published guidelines on the prevention and management of postpartum hemorrhage (PPH). Highlights of the guidelines include the following^[26]:

Prevention of PPH

To prevent PPH, a uterotonic drug should be routinely administered during the third stage of labor in all births. The preferred choice is oxytocin (either intravenous [IV] or intramuscular [IM]); if oxytocin is unavailable, other injectable uterotonics (eg, ergometrine/methylergometrine), oral misoprostol, or carbetocin (IM or IV) can be used.

For the early detection of uterine atony, abdominal uterine tonus assessment is warranted after all births.

To prevent PPH after cesarean delivery, administration of oxytocin (IV or IM) and controlled cord traction are recommended for removal of the placenta.

Management of PPH

The first-line uterotonic drug for the management of PPH is IV oxytocin. IM ergometrine, oxytocin-ergometrine fixed dose, or a prostaglandin drug (eg, sublingual misoprostol) can be used if IV oxytocin is unavailable or if oxytocin fails to control the bleeding.

In addition, IV tranexamic acid should be administered as soon as PPH is diagnosed but within 3 hours of either vaginal birth or cesarean delivery. A second dose is recommended if bleeding continues after 30 minutes or if bleeding restarts within 24 hours of the first dose.

Uterine massage should be included in the management of PPH. In addition, bimanual uterine compression or external aortic compression can be used to treat PPH that results from uterine atony following vaginal birth.

Uterine balloon tamponade is a nonsurgical treatment option if PPH fails to respond to uterotonic drugs or if these drugs are not available. Another conservative management option is uterine artery embolization.

If uterotonic agents and conservative measures fail to control PPH, surgical interventions are recommended, such as the use of compression sutures, uterine and hypogastric artery ligation, and hysterectomy.

Medication

Minino AM, Heron MP, Murphy SL, et al. National Vital Statistic Reports: Deaths 2004. US Department of Health and Human Services and the Centers for Disease Control and Prevention. August 21, 2007. Available at http://www.cdc.gov/nchs/data/nvsr/nvsr55/nvsr55_19.pdf.
World Health Organization. World Health Report 2005: Make Every Mother and Child Count. Available at http://www.who.int/whr/2005/whr2005_en.pdf. Accessed: September 10, 2008.
USAID (United States Agency for International Development). Postpartum Hemorrhage Prevention. USAID Postpartum Hemorrhage Prevention Initiative (POPPHI). Available at http://www.pphprevention.org/briefs_newsletters.php. Accessed: September 9, 2008.
PATH. Saving Mother's Lives: Initiative promotes proven strategy for preventing postpartum hemorrhage. PATH: Preventing Postpartum Hemorrhage. Available at http://www.path.org/projects/preventing_postpartum_hemorrhage.php. Accessed: September 9, 2008.
Miller S, Lester F, Hensleigh P. Prevention and treatment of postpartum hemorrhage: new advances for low-resource settings. J Midwifery Womens Health. 2004 Jul-Aug. 49(4):283-92. [QxMD MEDLINE Link]. [Full Text].
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Popovsky MA. Transfusion and lung Injury. Transfusion Clin Biol. 2001. 8:272-7.
Kicklighter EJ, Klein HG. Hemolytic transfusion reactions. Linden JV, Bianco C, eds. Blood Safety and Surveillance. New York: Marcel Dekker; 2001. 47-70.
Tintinalli JE, Kelen GD, Stapczynski JS. Gynecology and Obstetrics: Post Partum Hemorrhage. Emergency Medicine: A Comprehensive Study Guide. 6th. New York: McGraw Hill; 2004. 682.
Mousa HA, Blum J, Abou El Senoun G, Shakur H, Alfirevic Z. Treatment for primary postpartum haemorrhage. Cochrane Database Syst Rev. 2014 Feb 13. 2:CD003249. [QxMD MEDLINE Link].
Sentilhes L, Lasocki S, Ducloy-Bouthors AS, et al. Tranexamic acid for the prevention and treatment of postpartum haemorrhage. Br J Anaesth. 2015 Apr. 114 (4):576-87. [QxMD MEDLINE Link].
Ducloy-Bouthors AS, Jude B, Duhamel A, et al, for the EXADELI Study Group. High-dose tranexamic acid reduces blood loss in postpartum haemorrhage. Crit Care. 2011. 15 (2):R117. [QxMD MEDLINE Link].
WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017 May 27. 389 (10084):2105-2116. [QxMD MEDLINE Link].
Practice Bulletin No. 183 Summary: Postpartum Hemorrhage. Obstet Gynecol. 2017 Oct. 130 (4):923-925. [QxMD MEDLINE Link].
Quibel T, Ghout I, Goffinet F, Salomon LJ, Fort J, Javoise S, et al. Active Management of the Third Stage of Labor With a Combination of Oxytocin and Misoprostol to Prevent Postpartum Hemorrhage: A Randomized Controlled Trial. Obstet Gynecol. 2016 Oct. 128 (4):805-11. [QxMD MEDLINE Link].
Brown T. Oxytocin Without Misoprostol Best for Postpartum Hemorrhage Prevention. Medscape Medical News. September 09, 2016; Accessed: December 16, 2016.
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Winikoff B, Dabash R, Durocher J, Darwish E, Nguyen TN, Leon W, et al. Treatment of post-partum haemorrhage with sublingual misoprostol versus oxytocin in women not exposed to oxytocin during labour: a double-blind, randomised, non-inferiority trial. Lancet. 2010 Jan 16. 375(9710):210-6. [QxMD MEDLINE Link].
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[Guideline] World Health Organization (WHO). WHO recommendations for the prevention of postpartum haemorrhage. Geneva, Switzerland: World Health Organization (WHO). 2007. 116 p. [Full Text].
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Author

Maame Yaa A B Yiadom, MD, MPH Staff Physician, Department of Emergency Medicine, Cooper University Hospital, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School

Maame Yaa A B Yiadom, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Public Health Association, National Medical Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Daniela Carusi, MD, MSc Instructor, Obstetrics and Gynecology and Reproductive Biology, Harvard Medical School; Consulting Physician, Department of Obstetrics and Gynecology, Medical Director, Department of General Ambulatory Gynecology, Brigham and Women's Hospital

Daniela Carusi, MD, MSc is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Reproductive Health Professionals, Massachusetts Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Mark L Zwanger, MD, MBA, FACEP Emergency Medicine Physician

Mark L Zwanger, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Chief Editor

Bruce M Lo, MD, MBA, RDMS, FACEP, FAAEM, FACHE, FAAPL, CPE Chief, Department of Emergency Medicine, Sentara Norfolk General Hospital; Medical Director, Sentara Transfer Center; Professor and Assistant Program Director, Core Academic Faculty, Department of Emergency Medicine, Eastern Virginia Medical School; Board Member, American Academy of Emergency Medicine

Bruce M Lo, MD, MBA, RDMS, FACEP, FAAEM, FACHE, FAAPL, CPE is a member of the following medical societies: American Academy of Emergency Medicine, American Association for Physician Leadership, American College of Emergency Physicians, American College of Healthcare Executives, American Institute of Ultrasound in Medicine, Emergency Nurses Association, Medical Society of Virginia

Disclosure: Nothing to disclose.

Additional Contributors

Assaad J Sayah, MD, FACEP President and Chief Executive Officer, Cambridge Health Alliance

Assaad J Sayah, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society

Disclosure: Nothing to disclose.

Acknowledgements

Special thanks to Dr. Donnie Bell for his assistance with the "Imaging" section for this topic.

The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous author, Michael P Wainscott, MD, to the development and writing of this article.

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