Population: Women with postpartum hemorrhage.

Organizations

WHO 2012, ACOG 2017, ACR 2020, NICE 2022

Recommendations

–Uterotonics for the treatment of PPH:

• Intravenous oxytocin is the recommended agent.

• Alternative uterotonics:

Misoprostol 800-μg sublingual.

Methylergonovine 0.2-mg IM.

Carboprost 0.25-mg IM.

–Additional interventions for PPH:

• Isotonic crystalloid resuscitation.

• Bimanual uterine massage.

–Therapeutic options for persistent PPH:

• Tranexamic acid is recommended for persistent PPH refractory to oxytocin.

• Uterine artery embolization.

• Balloon tamponade.

–Therapeutic options for a retained placenta:

• Controlled cord traction with oxytocin 10 IU IM/IV.

• Manual removal of placenta.

Give single dose of first-generation antibiotic for prophylaxis against endometritis.

• Recommend against methylergonovine, misoprostol, or carboprost (Hemabate) for retained placenta.

–Role of imaging (ACR):

• Most of the causes of PPH can be diagnosed clinically, but imaging may play a role in diagnosis.

• Pelvic ultrasound (transabdominal and transvaginal with Doppler) is the imaging modality of choice for the initial evaluation of PPH.

• Contrast-enhanced CT of the abdomen and pelvis and CT angiogram of the abdomen and pelvis may be appropriate to determine if active ongoing hemorrhage is present, to localize the bleeding, and to identify the source of bleeding.

Sources

–Obstet Gynecol. 2017;130:e168-e186.

–J Am Coll Radiol. 2020;17:S459-S471.

–WHO Recommendations for the Prevention and Treatment of Postpartum Haemorrhage. Geneva: World Health Organization; 2012.

–www.nice.org.uk/guidance/cg190