Guideline:
Postpartum hemorrhage
Bibliographic Source(s)
- 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]
Guideline Status
This is the current release of the guideline.
Guideline Category
Evaluation
Management
Treatment
Intended Users
Physicians
Guideline Objective(s)
- To aid practitioners in making decisions about appropriate obstetric and gynecologic care
- To review the etiology evaluation and management of postpartum hemorrhage
Target Population
- 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
Interventions and Practices Considered
Evaluation/Management
- Multi-disciplinary approach with high clinical suspicion
- Laboratory evaluation of lost blood
- Testing for bleeding disorders among patients with menorrhagia
- Medical management including use of uterotonic agents
- Exploratory laparotomy
- Ultrasonography
- Drainage of hematomas
- Uterine compression or massage
- Tamponade: packing of the uterine cavity Foley catheter insertion Sengstaken-Blakemore tube insertion SOS Bakri tamponade balloon use
- Surgical management including uterine curettage and hysterectomy
- Arterial ligation or embolization
- Blood component therapy (donor or autologous): packed red cells platelets fresh frozen plasma cryoprecipitate
- Manual replacement of the uterine corpus
- Antibiotics
Poststabilization Management
- Prenatal vitamin and mineral capsules
- Additional iron tablets
- Erythropoietin
Major Outcomes Considered
- 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
Methods Used to Collect/Select Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
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.
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
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.
Methods Used to Analyze the Evidence
Systematic Review
Description of the Methods Used to Analyze the Evidence
Not stated
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
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.
Rating Scheme for the Strength of the 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.
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation
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.
Major Recommendations
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.
Clinical Algorithm(s)
None provided
Type of Evidence supporting the Recommendations
The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").
Potential Benefits
Appropriate evaluation and management of women with postpartum hemorrhage
Potential Harms
- Undiluted rapid oxytocin IV infusion causes hypotension.
- Care must be taken in performing curettage to avoid perforation of the uterus.
Contraindications
- Relative contraindication for 15-methylprostaglandin F2a in patients with hepatic renal and cardiac disease. Diarrhea fever tachycardia can occur.
- Avoid methylergonovine if patient is hypertensive.
- Avoid 15-methylprostaglandin F2a in asthmatic patients.
- Avoid dinoprostone if patient is hypotensive. Fever is common.
Qualifying Statements
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.
Description of Implementation Strategy
An implementation strategy was not provided.
Implementation Tools
Audit Criteria/Indicators
For information about availability see the "Availability of Companion Documents" and "Patient Resources" fields below.
IOM Care Need
Getting Better
IOM Domain
Effectiveness
Timeliness
Bibliographic Source(s)
- 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]
Adaptation
Not applicable: The guideline was not adapted from another source.
Source(s) of Funding
American College of Obstetricians and Gynecologists (ACOG)
Guideline Committee
American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins-Obstetrics
Composition of Group that Authored the Guideline
Not stated
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
This is the current release of the guideline.
Guideline Availability
Electronic copies: None available
Print copies: Available for purchase from the American College of Obstetricians and Gynecologists (ACOG) Distribution Center PO Box 4500 Kearneysville WV 25430-4500; telephone 800-762-2264 ext. 192; e-mail: sales@acog.org. The ACOG Bookstore is available online at the ACOG Web site.
Availability of Companion Documents
Proposed performance measures are included in the original guideline document.
Patient Resources
None available
NGC STATUS
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).
COPYRIGHT STATEMENT
This NGC summary is based on the original guideline which is subject to the guideline developer's copyright restrictions.
NGC Disclaimer
The National Guideline Clearinghouse™ (NGC) does not develop produce approve or endorse the guidelines represented on this site.
All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies relevant professional associations public or private organizations other government agencies health care organizations or plans and similar entities.
Guidelines represented on the NGC Web site are submitted by guideline developers and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx .
NGC AHRQ and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC AHRQ or its contractor ECRI Institute and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.
Readers with questions regarding guideline content are directed to contact the guideline developer.
Tools
No Quick Reference tools have been developed.