Re: Diagnosis and management of postpartum haemorrhage
We would like to thank Chandraharan and Krishna for their recent article highlighting the challenges of postpartum haemorrhage (PPH). The article provided a comprehensive review of the causes of PPH and the pharmacological and surgical interventions that may be required. However, we felt that the article did not adequately address the importance of early recognition of PPH and multidisciplinary team working that together make a difference to outcome; nor did the article reflect the recent RCOG guidance and research that has increased our understanding of coagulation changes which occur during PPH.
The management of postpartum haemorrhage requires a well-trained, effective multidisciplinary team with a defined escalation strategy. Team working and training is essential to achieve an optimal outcome in a rapidly deteriorating clinical situation (1). In Wales we have developed a national quality improvement project working to improve the care of women experiencing postpartum haemorrhage (OBS Cymru (2)). Our key themes are multidisciplinary team working, risk assessment, measurement of blood loss and point of care testing to guide blood product administration. None of these issues were addressed adequately in the review, yet we feel that they are the cornerstones of successful PPH management.
The authors describe the inaccuracy of estimating blood loss which can lead to underestimation of large blood loss and overestimation of smaller bleeds. Both situations have a significant impact on the care of a bleeding mother. We have found that the gravimetric measurement of blood loss after all deliveries is easy to perform, requires minimal equipment and reflects the fall in postpartum haemoglobin in larger bleeds (3). When undertaken cumulatively during a bleed this technique allows the clinical teams to escalate appropriately and act in a timely fashion. Measuring blood loss is often said to be difficult or impractical, yet we now have an 80% compliance rate after all vaginal deliveries and 90% after Caesarean deliveries across the 12 consultant led delivery units in Wales.
Our additional concern was the recommendation that red blood cells should be replaced in a 1:1 ratio with fresh frozen plasma (FFP). This is not in-line with current RCOG guidance and does not reflect the recent research that has increased our understanding of the coagulation changes occurring during PPH (4,5).
The RCOG guidance now specifies that if no haemostatic results are available and bleeding is continuing, then, if bleeding is continuing after 4 units of red blood cells have been given then 15 ml/kg of FFP should be infused until haemostatic test results are known. The RCOG only advise early FFP administration if haemostatic tests are not available for conditions such as placental abruption or amniotic fluid embolism where coagulopathy is an early feature. There is a clear recommendation not to give 1:1 plasma to red cell transfusion for all bleeding. 1:1 resuscitation is a practice supported by data derived from studies in major non obstetric trauma and there is no data that support its use during PPH. We have recently published a study reporting on the use of point of care visco-elastometric testing of coagulation during severe PPH. Women were stratified during the bleed based on their fibrinogen levels. It was found that a rapid point of care test of coagulation was practical and that very few women needed coagulation product support based on the results of the bedside test. Point of care testing of coagulation is described in the RCOG guidance and we have found that if used, very few women receive FFP, thus avoiding the many unnecessary infusions that would have resulted from 1:1 resuscitation (6).
1. Siassakos D, Fox R, Crofts JF, Hunt LP, Winter C, Draycott TJ. The management of a simulated emergency: better teamwork, better performance. Resuscitation 2011; 82(2): 203-6.
3. Lilley G et al. Measurement of blood loss during postpartum haemorrhage. Int J Obst Anesth 2015; 24(1): 8-14.
4. Mavrides E,Allard S,Chandraharan E,Collins P,Green L,Hun tBJ,RirisS,Thomson AJ on behalf of the Royal College of Obstetricians and Gynaecologists. Prevention and management of postpartum haemorrhage. BJOG 2016; 124: e106–e149.
5. Collins PW et al. Viscoelastometric-guided early fibrinogen concentrate replacement during postpartum haemorrhage: OBS2, a double-blind randomized controlled trial. BJA 2017; 119(3): 411-421.
6. Collins PW et al. Viscoelastometry guided fresh frozen plasma infusion for postpartum haemorrhage: OBS2, an observational study. BJA 2017; 119(3):422-434.
Competing interests: OBS Cymru is an all Wales Quality Improvement Project sponsored by Welsh Government, 1000 Lives and Werfen.