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Diagnosis and management of postpartum haemorrhage

BMJ 2017; 358 doi: (Published 27 September 2017) Cite this as: BMJ 2017;358:j3875
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Infographic available

A visual summary of suggested approaches for the management of primary and secondary postpartum haemorrahage

Rapid Response:

Re: Diagnosis and management of postpartum haemorrhage

Chandraharan and Krishna define postpartum haemorrhage (PPH) as blood loss over 500mL from the female genital tract. What is often not considered is the fact that visual estimation of blood loss following both vaginal and Caesarean section delivery may be grossly inaccurate and therefore of limited clinical use (1). Specifically, significant underestimation in three key areas (floor spillages, surgical swab capacity and massive PPH) were identified by Bose et al in all professional groups (2), with resultant clinical care implications. Overestimation of blood volume losses may result in unnecessary cross matching and care in the high dependency unit. Bose et al suggest a pictorial algorithm may be useful to increase the accuracy of visual blood loss estimation, along with clinical reconstruction and simulation training.

Furthermore, whilst hysterectomy may be definitive management in massive post-partum haemorrhage as suggested by Chandraharan and Krishna, stepwise uterine devascularisation, internal iliac artery ligation and selective arterial occlusion or embolisation by interventional radiology may also be other measures to be considered, where expertise and facilities allow, thereby preserving the uterus where fertility is desired (3).

In addition to considering acute management of PPH, the RCOG greentop guidelines outline the importance of identifying high risk patients who may experience post-partum haemorrhage in the antenatal period. This allows treatment to be administered where correctable factors such as anaemia are noted in good time, or preparation for prevention of PPH by the use of an active third stage.

Given that PPH remains a common emergency, antenatal assessment and counselling together with regular multidisciplinary training remains key to minimising its impact on our patients.

1. Dildy GA III, Paine AR, George NC, Velasco C. Estimating blood loss: can teaching significantly improve visual estimation? Obstet Gynecol 2004;104:601–6.
2. Bose P, Regan F, Paterson-Brown S. Improving the accuracy of estimated blood loss at obstetric haemorrhage using clinical reconstructions. BJOG 2006; 113:919–924.
3. Mavrides E, Allard S, Chandraharan E, Collins P, Green L, Hunt BJ, Riris S, Thomson AJ on behalf of the Royal College of Obstetricians and Gynaecologists. Prevention and management of postpartum haemorrhage.

Competing interests: No competing interests

30 September 2017
Shreelata T Datta
Consultant Obstetrician and Gynaecologist
Knig's College Hospital
King's College Hospital