Postpartum haemorrhage lacks a standard defintion and most of the international guidelines disagree on basic elemsnts of its management. Most of the time, people define in in terms of volume, that being 500ml in the 24 hours following delivery. Standard peripartum management should include some uterotonic, be it oxytocin, ergometrin or misoprostol. Management of PPH starts with these drugs, moves on to add tranexamic acid and massive 1:1:1 transfusion (maybe even Factor VIIa) and continues through to mechanical compression strategies such as balloon tamponade. Ultimately, definitive management techniques can range from angioembolisation and "stepwise uterine devascularisation" by ligation and finally hysterectomy.
Question 17 from the second paper of 2017 was the first time anybody ever got asked about postpartum haemorrhage in the CICM exam. The examiners wanted to know about the advantages and disadvantages of all the various methods of controlling it. The next time this topic emerged was Question 17 from the second paper of 2018, where the focus shifted to causes and management. Fortunately, with at least one past paper SAQ raising awareness of the candidates, the pass rate had improved from 40.8% to 67.2%. The next appearance was as Question 3 from the second paper of 2020, which was basically identical. We were hit with this again in Question 22 from the first paper of 2021. In short, these questions are becoming a fixed feature of the exam.
As far as published sources go, Chapter 24 from Oh's Manual ("General obstetric emergencies") by Winnie TP Wan and Tony Gin has a brief blurb on "severe obstetric haemorrhage" which offers a short introduction to the subject. What's there is probably not enough to answer Question 17 up to the level of a passing grade. Therefore, even the time-poor candidate will need to read widely. The most comprehensive recent review is probably by the WHO (Recommendations for the prevention and treatment of postpartum haemorrhage, 2012). That's over 40 pages for two SAQs, which does not seem to be a favourable marks-per-effort ratio. A shorter article by Mousa et al (2014) list many treatments, but do not go deeply into the advantages and disadvantages, which basically also fails to answer the question. Weeks (2015) wrote a nice review which does discuss the pros and cons, but fails to cover everything. Unfortunately the author of this summary has had to compile this table of advantages and disadvantages without any one specific reference to recommend to the candidates.
Traditionally, it is the loss of more than 500ml of blood in the 24 hours following delivery. Pretty much nobody agrees with this traditional WHO definition, because:
Dahlke et al (2015) looked at four international guidelines and found that they each had a different definition of PPH. The more disturbing variation was in the recommendations for things like balloon tamponade and hysterectomy, where there were no clear guidelines in the guidelines. Each statement made different recommendations on the basis of the same evidence.
The college answer to Question 17 from the second paper of 2018 recommends to classify the possible causes in the "4 T's" tone, trauma, tissue and thrombin, where:
That may represent the minimum expected of a hastily scribbled CICM SAQ answer. For those playing at home (eg. doing these SAQs under exam conditions), some hasty scribbles may not match the college model answer, yet still remain accurate. In those cases it would help to have a broader range of causes.
Thus:
At some stage, the college may ask for a list of risk factors. One such list is provided by Sheiner et al (2005); this specifically refers to early PPH (i.e. within 24 hours of delivery):
Method | Advantages | Disadvantages |
Mechanical haemostasis methods | ||
Uterine massage |
|
|
Bimanual compression |
|
|
Manual aortic compression |
|
|
Pharmacological means of encouraging uterine contraction | ||
Oxytocin |
|
|
Ergometrine |
|
|
Carboprost |
|
|
Misoprostol |
|
|
Pharmacological measures to promote haemostasis | ||
Tranexamic acid |
|
|
Factor VIIa |
|
|
Surgical or radiological methods of haemostasis | ||
Gause pack tamponade |
|
|
Balloon tamponade |
|
|
Angio-embolisation |
|
|
Ligation of the uterine or common iliac artery |
|
|
Hysterectomy |
|
|
For extra credit, the trainees were expected to mention the WOMAN trial (Shakur et al, 2017). Bleeding PPH patients were randomised to receive 1g of tranexamic acid (and another 1g if needed). A whopping 20,060 patients were enrolled. The difference in death from haemorrhage was 1.5% vs 1.9%, in favour of tranexamic acid by 0.4% of absolute risk reduction - a difference which only achieved statistical significance because the numbers were massive and because the sample size was increased by 5000 patients mid-study. The number needed to treat are 267.
This structure and a lot of the components are borrowed from the RANZCOG statement C-Obs 43.
Resuscitation
Specific management
Oh's Manual, Chapter 64 ("General obstetric emergencies") by Winnie TP Wan and Tony Gin, p. 684
Mousa, Hatem A., et al. "Treatment for primary postpartum haemorrhage." The Cochrane Library (2014).
Tunçalp, Özge, G. Justus "Prostaglandins for preventing postpartum haemorrhage."Hofmeyr, and A. Metin Gülmezoglu. "Prostaglandins for preventing postpartum haemorrhage." Cochrane Database Syst Rev 8.8 (2012): CD000494.
Alfirevic, Zarko, et al. "Use of recombinant activated factor VII in primary postpartum hemorrhage: the Northern European registry 2000–2004." Obstetrics & Gynecology 110.6 (2007): 1270-1278.
Dahlke, Joshua D., et al. "Prevention and management of postpartum hemorrhage: a comparison of 4 national guidelines." American journal of obstetrics and gynecology 213.1 (2015): 76-e1.
Doumouchtsis, S. K., et al. "Menstrual and fertility outcomes following the surgical management of postpartum haemorrhage: a systematic review." BJOG: An International Journal of Obstetrics & Gynaecology 121.4 (2014): 382-388.
Smith, J., and H. A. Mousa. "Peripartum hysterectomy for primary postpartum haemorrhage: incidence and maternal morbidity." Journal of obstetrics and gynaecology 27.1 (2007): 44-47.
World Health Organization. WHO recommendations for the prevention and treatment of postpartum haemorrhage. World Health Organization, 2012.
Weeks, A. "The prevention and treatment of postpartum haemorrhage: what do we know, and where do we go to next?." BJOG: An International Journal of Obstetrics & Gynaecology122.2 (2015): 202-210.
Edhi, Muhammad Muzzammil, et al. "Post partum hemorrhage: causes and management." BMC research notes6.1 (2013): 236.
Sheiner, Eyal, et al. "Obstetric risk factors and outcome of pregnancies complicated with early postpartum hemorrhage: a population-based study." The Journal of Maternal-Fetal & Neonatal Medicine 18.3 (2005): 149-154.
Mousa, Hatem A., and Steven Walkinshaw. "Major postpartum haemorrhage." Current opinion in Obstetrics and Gynecology13.6 (2001): 595-603.
Mousa, Hatem A., et al. "Treatment for primary postpartum haemorrhage." Cochrane Database Syst Rev 2.2 (2014): CD003249.
Hibbs, Stephen P., et al. "Post‐partum haemorrhage and tranexamic acid: a global issue." British journal of haematology 180.6 (2018): 799-807.