III Methodology
Basic principles
The method used to prepare this guideline was determined by the class to which this
guideline was assigned. The AWMF Guidance Manual (version 2.0) has set out the respective
rules and requirements for different classes of guidelines. Guidelines are differentiated
into lowest (S1), intermediate (S2), and highest (S3) class. The lowest class is defined
as consisting of a set of recommendations for action compiled by a non-representative
group of experts. In 2004, the S2 class was divided into two subclasses: a systematic
evidence-based subclass (S2e) and a structural consensus-based subclass (S2k). The
highest
S3 class combines both approaches.
This guideline was classified as: S2k .
Grading of recommendations
The grading of evidence based on the systematic search, selection, evaluation, and
synthesis of an evidence base which is then used to grade the recommendations is not
envisaged for S2k guidelines. The individual statements and recommendations are only
differentiated by syntax, not by symbols ([Table
3 ]).
Tab. 3 Grading of recommendations.
Description of binding character
Expression
Strong recommendation, highly binding
must/must not
Regular recommendation, moderately binding
should/should not
Open recommendation, not binding
may/may not
Statements
Expositions or explanations of specific facts, circumstances, or problems without
any
direct recommendations for action included in this guideline are referred to as
“statements.” It is not possible to provide any information about the level of evidence
for these statements.
Achieving consensus and level of consensus
At structured NIH-type consensus-based conferences (S2k/S3 level), authorised
participants attending the session vote on draft statements and recommendations. The
process is as follows. A recommendation is presented, its contents are discussed,
proposed
changes are put forward, and all proposed changes are voted on. If a consensus (> 75%
of votes) is not achieved, there is another round of discussions, followed by a repeat
vote. Finally, the extent of consensus is determined, based on the number of participants
([Table 4 ]).
Tab. 4 Level of consensus based on extent of
agreement.
Symbol
Level of consensus
Extent of agreement in percent
+++
Strong consensus
> 95% of participants agree
++
Consensus
> 75 – 95% of participants agree
+
Majority agreement
> 50 – 75% of participants agree
–
No consensus
< 51% of participants agree
Expert consensus
As the term already indicates, this refers to consensus decisions taken relating
specifically to recommendations/statements issued without a prior systematic search
of the
literature (S2k) or where evidence is lacking (S2e/S3). The term “expert consensus”
(EC)
used here is synonymous with terms used in other guidelines such as “good clinical
practice” (GCP) or “clinical consensus point” (CCP). The strength of the recommendation
is
graded as previously described in the chapter Grading of recommendations but
without the use of symbols; it is only expressed semantically (“must”/“must not” or
“should”/“should not” or “may”/“may not”).
IV Guideline
1 Background
The reported incidence of postpartum haemorrhage (PPH) is 1 – 3% of all deliveries.
Prospective studies have reported that quantitative measurement of blood loss resulted
in
a PPH rate of around 10% [1 ], [2 ], [3 ], [4 ]. The
incidence of postpartum haemorrhage (PPH) is constantly increasing, mainly due to
the rise
in cases with uterine atony and placental implantation disorders as well as rising
rates
of operative vaginal and caesarean section deliveries leading to higher primary blood
loss
and, in cases delivered by caesarean section, higher PPH rates in subsequent pregnancies
[5 ], [6 ], [7 ], [8 ], [9 ], [10 ], [11 ].
Life-threatening PPH affects around ca. 2/1000 deliveries in the West, with a reported
rate of severe maternal morbidity of around 3/1000 deliveries [12 ], [13 ], [14 ], [15 ], [16 ], [17 ]. This makes PPH the cause of around 30%
of all maternal deaths in low and middle-income countries and 13% of maternal deaths
in
industrialised countries [16 ]. Most maternal deaths from
PPH are avoidable, and in 60 – 80% of all cases they are the result of major substandard
care [16 ], [18 ] – [21 ]. It is especially important to be aware that the extent of
bleeding will be underestimated by 30 – 50% if assessed visually [22 ] – [25 ].
The “4 Tʼs” is an English mnemonic used to summarise the causes of PPH (combinations
of
all four causes are the norm) ([Table 5 ]) [26 ]:
Tab. 5 The 4 Tʼs: causes of PPH [26 ].
Cause
Potential trigger
T one (focal or diffuse uterine atony – responsible for at least 80% of
PPHs [2 ])
Idiopathic atony
Uterine overdistension (from multiparity, hydramnios, fetal
macrosomia)
Tocolytics
Precipitate or delayed delivery/prolonged labour
Oxytocin tachyphylaxis (after prolonged administration of oxytocin)
Chorioamnionitis
Uterine fibroids
T issue (placenta)
Retained placenta
Placenta accreta spectrum (morbidly adherent placenta, placenta
accreta/increta/percreta)
Placental remnants
T rauma
Vulvovaginal injuries
Cervical tears
Uterine tear from surgical extension of uterotomy
Episiotomy/perineal tear
Uterine rupture
Uterine inversion
T hrombin (coagulopathy)
Pregnancy-induced:
Disseminated intravascular coagulation (DIC) (e.g., with preeclampsia, HELLP
syndrome, intrauterine fetal death [IUFD], placental abruption, amniotic fluid
embolism)
Other:
occurs in the context of a PPH: factor deficiencies (loss, consumption,
dilution)
pre-existing: von Willebrand-Jürgens syndrome, plasmatic coagulation
disorders, thrombopathies, coagulopathies
Tone (postpartum uterine atony),
Trauma (injury of the birth canal),
Tissue (retained placental tissue or detachment disorders),
Thrombin (coagulation decompensation, coagulopathy).
2 Definition
Consensus-based recommendation 2.E1
Expert consensus
Level of consensus +++
The following definition of PPH is recommended:
Irrespective of the visible blood loss, PPH must be assumed if the patient
presents with clinical signs of haemorrhagic shock (shock index
[HF/RRsys ] > 0.9).
Clinically, a blood loss of between 500 and 1500 is usually tolerated without symptoms
of
shock [27 ], [28 ]. Symptoms
such as agitation, clouding of consciousness, cold sweat, paleness, tachycardia,
hypotension, hyperventilation, and oliguria are already signs of severe haemorrhagic
shock
(shock index [HF/RRsys ] > 0.9) [29 ], [30 ].
PPH is categorised into primary and secondary PPH, according to the time when it occurs
[26 ]:
Primary (acute) bleeding:
usually occurs just a few hours postpartum (often already in the delivery room or
operating room).
The cause is usually atony (> 80%) or trauma resulting in blood loss (e.g., occult
intraabdominal or retroperitoneal bleeding).
Clinically this leads to haemodynamic derangement with a rapid decrease in blood
pressure (hypovolaemia).
Secondary (subacute) bleeding/late postpartum bleeding:
Incidence: occurs in around 0.2 to 2.5% of postpartum women
Postpartum women often only start bleeding in the postpartum ward or at home.
Causes of this “secondary” PPH are usually placental remnants, subinvolution of the
uterus or infection.
Clinically, this leads to haemodynamic derangement with tachycardia with a rapid
decrease in blood pressure (hypovolaemic-haemorrhagic shock).
3 Risk stratification and prevention
Consensus-based recommendation 3.E1
Expert consensus
Level of consensus +++
Reference: [31 ]
On ultrasound scans performed in the 1st and 2nd trimester of pregnancy in
high-risk cases (e.g., status post repeated caesarean section), the location and
structure of the placenta may provide hints of a disorder of placentation. In
cases with low lying placenta in the 2nd trimester presence of placenta praevia
and/or vasa praevia should be ruled out and documented, if necessary by
performing additional ultrasound examinations.
Consensus-based recommendation 3.E2
Expert consensus
Level of consensus +++
Especially in women with a history of risk factors (previous surgeries, esp.
previous caesarean section and transmural myomectomy) or clinical findings such
as placenta praevia, the presence of PAS should be considered. Further
diagnostic ultrasound examinations may aid in the diagnostic work-up.
A detailed medical history, diagnostic ultrasound examinations during prenatal care,
estimation of the risk of bleeding, counselling and delivery planing in an appropriate
maternity hospital, and timely preparations for an increased loss of blood may reduce
the
risk of PPH and its consequences for maternal morbidity and mortality [32 ].
The main risk management problems for PPH are [33 ], [34 ], [35 ], [36 ]:
delayed diagnosis and/or therapy due to underestimation of the actual loss of
blood,
delay in providing blood and coagulation products,
lack of or non-compliance with simple instructions,
lack of adequate training and further training,
inadequate or ineffective communication within the interdisciplinary team,
deficits in the organisational structure,
delay in implementing and realising treatment standards.
3.1 Risk factors for PPH
A number of risk factors for PPH have been identified. Risk factors can be categorized
into sociodemographic and obstetric (based on previous history and current) risk factors
([Table 6 ]).
Tab. 6 Risk factors for PPH ([26 ] modified from [37 ]).
Blood loss
OR or range
> 500 ml
> 1000 ml
Sociodemographic risk factors
Obesity (BMI > 35)
1.6
Maternal age (≥ 30 years)
1.3 – 1.4
1.6
Obstetric risk factors
Placenta praevia
4 – 13.1
15.9
Premature placental detachment
2.9 – 12.6
2.6
Retained placenta
4.1 – 7.8
11.7 – 16.0
Prolonged placental stage
7.6
Preeclampsia
5.0
Multiple pregnancy
2.3 – 4.5
2.6
Status post PPH
3.0 – 3.6
Fetal macrosomia
1.9 – 2.4
HELLP syndrome
1.9
Hydramnios
1.9
(Prolonged) oxytocin augmentation
1.8
Induction of labour
1.3 – 2
2.1 – 2.4
Protracted labour
1.1 – 2
Fibroids
Uterine malformations
Grand multiparity
Surgical risk factors
Emergency caesarean section
3.6
Elective caesarean section
2.5
Operative vaginal birth
1.8 – 1.9
Episiotomy
1.7 – 2.21
2.07
Perineal tear
1.7
2.5
Other risk factors
Antepartum bleeding
3.8
Von Willebrand syndrome (esp. types 2 and 3)
3.3
Anaemia (< 9 g/dl)
2.2
3.2 Risk stratification
A general risk stratification to predict PPH (e.g., using a score) does not currently
exist and is not recommended for use in practice.
Known risk factors – particularly those associated with a high relative risk of PPH
–
must be considered on a case-by-case basis when taking the relevant preventive (e.g.,
organisational) steps [26 ].
Recent reports have confirmed the purpose and benefit of standardised treatment
algorithms and their review during regular audits [32 ], [38 ], [39 ].
An interdisciplinary (anaesthesiology and intensive care medicine, obstetrics)
algorithm, known as the PPH 2022 algorithm, has been developed as a transnational
algorithm for Germany, Austria, and Switzerland ([Fig. 1 ]) [26 ].
Fig. 1 Interdisciplinary algorithm (“PPH 2022”) for the management of PPH,
based on: PPH Guideline 2022 AWMF Registry No. 015/063 of the BVF, DGGG (AGG),
DeGIR, DEGUM, DGAI, DGHWI, DGKL, DGPM, DGPGM, DHV, DIVI, EFCNI (Pat.), GTH, OEGARI,
OEGGG, SGGG, SSAPM (listed alphabetically) [26 ].
[rerif]
3.3 Placental detachment disorders: placenta praevia/placenta accreta spectrum
(PAS)
3.3.1 Placenta praevia
Consensus-based statement 3.S1
Expert consensus
Level of consensus +++
References: [40 ], [41 ], [42 ], [43 ], [44 ]
A previous caesarean section is associated with a higher risk of placenta
praevia in subsequent pregnancies. The risk increases with the number of
deliveries by caesarean section. The risk of placenta praevia is also higher
following curettage (e.g., termination of pregnancy, miscarriage) or
multiple pregnancies.
Consensus-based statement 3.S2
Expert consensus
Level of consensus +++
References: [45 ], [46 ], [47 ], [48 ]
In vitro fertilisation (IVF) procedures increase the risk of placenta
praevia.
Consensus-based statement 3.S3
Expert consensus
Level of consensus +++
Reference: [48 ]
Nicotine abuse increases the risk of placenta praevia.
3.3.1.1 Diagnosing placenta praevia
Consensus-based recommendation 3.E3
Expert consensus
Level of consensus +++
References: [31 ], [49 ]
Ultrasound examination in the 2nd trimester of pregnancy must determine
and record the location, structure and umbilical cord insertion site of
the placenta. If ultrasound examination shows a low-lying placenta,
placenta praevia should be excluded and the patient should be investigated
for vasa praevia, if necessary, by performing another ultrasound
examination; ultrasound findings should be documented.
Consensus-based recommendation 3.E4
Expert consensus
Level of consensus +++
Reference: [50 ]
If ultrasound examination in the 2nd trimester of pregnancy shows a
low-lying placenta (≤ 20 mm distant from the internal cervical os) or
placenta praevia, another assessment of the placental location must be
carried out to confirm the diagnosis at 28 + 0 weeks of gestation and, if
necessary, at 32 + 0 weeks of gestation.
Consensus-based recommendation 3.E5
Expert consensus
Level of consensus +++
References: [50 ], [51 ]
Transvaginal ultrasound assessment must be carried out if there is a
suspicion of placenta praevia, vasa praevia or placenta accreta
spectrum.
Consensus-based statement 3.S4
Expert consensus
Level of consensus +++
Reference: [50 ]
Transvaginal ultrasound is the gold standard to diagnose placenta praevia
(sensitivity 87.5%, specificity 98.8%, PPV 93.3%, NPV 97.6%).
Consensus-based recommendation 3.E6
Expert consensus
Level of consensus +++
References: [50 ], [52 ], [53 ], [54 ], [55 ]
In cases with placenta praevia, measurement of cervical length may be
used to plan further management in asymptomatic pregnant women. A short
cervix before 34 + 0 weeks of gestation increases the risk of emergency
C-section and massive PPH. In principle, if placenta praevia totalis has
been confirmed, inpatient admission should be considered from week 24 + 0
of gestation.
3.3.2 Placenta accreta spectrum (PAS)
Disorders of placental implantation are currently grouped together under the term
PAS
(placenta accreta spectrum).
Consensus-based statement 3.S5
Expert consensus
Level of consensus +++
References: [43 ], [50 ], [56 ], [57 ], [58 ]
The main risk factors for PAS are disorders of placental implantation in a
previous pregnancy, previous caesarean section, and other uterine surgeries
(e.g., transmural myomectomy). The risk increases with the number of
previous caesarean sections. Placenta praevia is an independent risk factor
for PAS.
Consensus-based recommendation 3.E7
Expert consensus
Level of consensus +++
References: [18 ], [59 ]
In principle, pregnant women with suspected disorders of placentation must
present early to a maternity hospital with a suitable organisational
structure where, if the suspicion is confirmed, the patient should be
treated by an experienced multidisciplinary team (“at the optimum time by
the best team”).
3.3.2.1 Diagnosing placenta accreta spectrum
Consensus-based statement 3.S6
Expert consensus
Level of consensus +++
Reference: [50 ]
If PAS is suspected antenatally, taking the appropriate steps will reduce
maternal morbidity and mortality.
Population studies have shown that PAS was not recognised prenatally in 50 – 66% of
cases [57 ], [60 ];
even specialised centres do not detect around ⅓ of cases prenatally [61 ].
Consensus-based recommendation 3.E8
Expert consensus
Level of consensus +++
Reference: [26 ]
Implantation disorders (placenta accreta spectrum) must be considered,
especially if the patientʼs medical history indicate that she has a high
risk of PAS (previous surgeries) or examination findings (placenta
praevia) show that the patient is at high risk.
3.3.2.1.1 (Doppler) sonography
Consensus-based recommendation 3.E9
Expert consensus
Level of consensus +++
Reference: [26 ]
A detailed ultrasound examination must be carried out if PAS is
suspected. Additional MRI may be considered in cases where the findings
are unclear.
Consensus-based statement 3.S7
Expert consensus
Level of consensus +++
References: [62 ], [63 ], [64 ]
As the majority of PAS are a consequence of low-lying implantation of the
placenta in the area of the caesarean section scar, transvaginal
ultrasound examination in the 1st and 2nd trimester of pregnancy may
contribute to early (suspected) diagnosis and direct the further
management of the patient.
Sonographic signs of PAS include the following (not all of which must always be
detectable) ([Table 7 ]).
Tab. 7 (Doppler) ultrasound signs of PAS (modified
from [50 ], [65 ]).
Ultrasound findings
Description
B-mode image
Loss of clear zone
Loss or irregularity of the hypoechoic retroplacental clear zone in the
myometrium beneath the placental bed
“Moth-eaten” lacunae
Image shows numerous irregular (“moth-eaten”) lacunae, some of which show
turbulent flow in B-mode, typically perpendicular at the uterovesical
interface
Bladder wall interruption
Loss or irregularity of the hyperechoic layer of the bladder wall
Myometrial thinning
Thinning (< 1 mm) or loss of myometrium in the area of the
placenta
Placental bulge
Outpouching of the uterine serosa from the expected plane, caused by
abnormal placental tissue, although the serosa appears intact
Focal exophytic placental tissue
Placental tissue breaks through the uterine serosa (e.g., into the
bladder)
Doppler sonography
Uterovesical hypervascularity
Increased imaging of irregular vascular perfusion between the myometrium
and the posterior wall of the bladder (numerous spiral vessels with
bidirectional flow)
Subplacental hypervascularity
Increased imaging of irregular vascular perfusion in the placental bed
(numerous spiral vessels with bidirectional flow)
Bridging vessels
Imaging of vessels which extend from the placenta through the myometrium
and serosa into the bladder or other organs – often perpendicular to the
myometrium
Afferent vessels to the placental lacunae
Vessels with high velocity of blood flow from the myometrium to the
lacunae
3-D Doppler sonography
Intraplacental hypervascularity (power Doppler)
Complex irregular placental vessels with tortuous courses
3.3.2.1.2 Magnetic resonanc imaging (MRI)
Consensus-based statement 3.S8
Expert consensus
Level of consensus +++
Reference: [26 ]
MRI examinations are not routinely carried out to diagnose PAS but may
offer additional information in cases where findings are inconclusive.
Consensus-based recommendation 3.E10
Expert consensus
Level of consensus +++
References: [66 ], [67 ], [68 ]
Contrast media (gadolinium) must not be routinely used to diagnose
PAS.
3.3.2.1.3 Biomarkers
Consensus-based recommendation 3.E11
Expert consensus
Level of consensus +++
References: [26 ], [69 ], [70 ]
Biomarkers must only be used during diagnostic investigations for PAS in
the context of registered clinical studies.
4 Prevention of PPH
4.1 Prevention of PPH during vaginal delivery
4.1.1 Active management of the third stage of labour in vaginal
deliveries
Consensus-based recommendation 4.E1
Expert consensus
Level of consensus ++
References: [71 ], [72 ], [73 ], [74 ]
Active management of third stage of labour (AMTSL) reduces the risk of PPH
by up to 66% and must therefore be recommended for every delivery.
The most decisive step consists of the prophylactic administration of uterotonic
drugs [75 ], [76 ];
basically, it is important to ensure the following [26 ]:
provide antenatal information about management in the third stage of labour and
take the wishes of the pregnant woman into consideration (consent).
it is important to allow the mother (and her birth companion) and the neonate to
get to know each other (bonding); this promotes the endogenous release of oxytocin
and should be facilitated so that they can be undisturbed – as long as the
situation permits – during the first hour together.
Consensus-based recommendation 4.E2
Expert consensus
Level of consensus +++
Reference: [26 ]
During vaginal delivery, early clamping and cutting of the umbilical cord
immediately after the delivery of the neonate accompanied by controlled
traction on the umbilical cord does not reduce postpartum haemorrhage and
should not be carried out.
4.1.2 Medication prophylaxis against PPH
4.1.2.1 Uterotonic drugs
Consensus-based recommendation 4.E3
Expert consensus
Level of consensus +++
Reference: [26 ]
Oxytocin 3 – 5 IU IV or carbetocin 100 µg IV (both administered by short
infusion) may be used for medication prophylaxis against PPH or
administered IM in cases of vaginal delivery; carbetocin is effective for
longer and has the same side-effects rate.
4.1.2.1.1 Oxytocin/carbetocin
When oxytocin or carbetocin are administered IV, it is important to remember that
a
quick (bolus) injection will lead to a decrease in blood pressure with reflex
tachycardia [77 ], [78 ]. That is why these agents should be administered by short infusion; a
slow IV injection may be necessary. Alternatively, both oxytocin and carbetocin may
be administered IM.
4.1.2.1.2 Methylergometrine
Consensus-based recommendation 4.E4
Expert consensus
Level of consensus +++
References: [79 ], [80 ]
Methylergometrine has more side effects than oxytocin and carbetocin, and
should therefore not be administered as a first choice medication.
4.1.2.1.3 Misoprostol
Consensus-based recommendation 4.E5
Expert consensus
Level of consensus +++
References: [26 ]
Misoprostol is less effective than oxytocin and carbetocin and should
therefore not be administered as a first choice medication.
4.1.2.1.4 Antifibrinolytic agents
Consensus-based recommendation 4.E6
Expert consensus
Level of consensus +++
References: [81 ], [82 ]
Tranexamic acid must not be routinely used for bleeding prophylaxis but
only therapeutically following a diagnosis of PPH.
4.2 Prevention of PPH during caesarean section
Consensus-based recommendation 4.E7
Expert consensus
Level of consensus +++
References: [26 ], [83 ], [84 ], [85 ]
Similar to vaginal deliveries, medication must be administered as a
prophylaxis against PPH in every caesarean section delivery. As with vaginal
births, oxytocin 3 – 5 IU IV or carbetocin 100 µg IV may be administered (both
by short infusion); carbetocin is effective for a longer period and has the
same side-effects rate.
4.3 Prevention when risk factors are present
Consensus-based recommendation 4.E8
Expert consensus
Level of consensus +++
Reference: [26 ]
In hospital, the following measures must be implemented before inducing
labour if the patient has known risk factors:
obstetrician and anaesthesiologist must both be in-house and have been
informed; an experienced obstetrician and experienced anaesthesiologist
must be on call
placement of adequate intravenous access during delivery in every woman
giving birth; large-lumen venous access points may be placed for bleeding
complications
provision of uterotonic drugs: oxytocin, carbetocin, sulprostone
Check logistics:
provision of antifibrinolytic agents (tranexamic acid)
urgent laboratory tests can be carried out (blood count, arterial blood
gas analysis [ABG], aPTT, Quick or INR and, if available, fibrinogen,
factor XIII, viscoelastic test [VET])
blood bank/blood depot: crossmatch test; red cell concentrates, fresh
frozen plasma and platelet concentrates available in good time
Availability of coagulation factors, fibrinogen, factor XIII, recombinant
Factor VIIa (rFVIIa).
5 General (emergency) measures and diagnostic steps to determine causes
5.1 Estimating the severity of bleeding
Consensus-based statement 5.S1
Expert consensus
Level of consensus ++
References: [26 ], [32 ], [86 ], [87 ], [88 ], [89 ]
Visual estimates of blood loss are inaccurate. Validated measurement methods
to determine the extent of blood loss should be preferred.
Consensus-based recommendation 5.E1
Expert consensus
Level of consensus +++
Reference: [26 ]
All underlays, pads, linen “soaked” with blood and all coagula must be
collected and weighed if the bleeding increases/in cases with PPH.
Consensus-based recommendation 5.E2
Expert consensus
Level of consensus +++
References: [29 ], [30 ]
The patientʼs clinical symptoms (signs of hypovolaemia) must be considered
when estimating the extent of blood loss: shock index (HF/RRsys )
> 0.9.
Consensus-based recommendation 5.E3
Expert consensus
Level of consensus +++
Reference: [26 ]
When caring for a bleeding patient, Hb values must be checked in good time
and regularly; it is important to be aware that Hb levels will be slow to
respond and cannot replace gravimetric measurements. Early signs of critical
hypovolaemia may include reduced base excess (BE) levels in venous blood gas
analysis and elevated lactate levels. Alarming signs: BE < −6 mmol/l and
lactate > 4 mmol/l.
5.2 Communication and multidisciplinary teams
Consensus-based statement 5.S2
Expert consensus
Level of consensus ++
Reference: [26 ]
From the start, the woman giving birth/postpartum woman and her companion(s)
must be informed about the bleeding and the approach taken in words that can
be understood by laypersons.
Consensus-based recommendation 5.E4
Expert consensus
Level of consensus +++
Reference: [26 ]
Depending on the situation/the loss of blood, experienced midwives and
obstetricians as well as the anaesthesiologist and other medical specialists
must be informed and consulted (see PPH algorithm, [Fig. 1 ]).
5.3 General measures against PPH
Consensus-based statement 5.S3
Expert consensus
Level of consensus +++
References: [26 ], [90 ], [91 ]
In addition to general measures (for haemodynamic stabilisation or uterine
compression → Hamilton procedure), treatment of PPH consists of the
appropriate drug therapy and/or surgical and/or interventional therapy which
must be quick, coordinated, and often performed simultaneously (see PPH
algorithm, [Fig. 1 ]).
6 Pharmaceutical therapy to treat PPH
6.1 Uterotonic drugs
6.1.1 Oxytocin IV (poss. IM)
Consensus-based recommendation 6.E1
Expert consensus
Level of consensus +++
References: [26 ], [92 ], [93 ], [94 ]
Oxytocin must be used as first-line therapy for primary PPH. Compared to
misoprostol, oxytocin is more effective, particularly after vaginal birth,
and has fewer side effects.
Overall, a maximum of 6 – 10 IU may be administered as a short
infusion:
The onset of effect following IV administration occurs (with a half-life period of
around 10 min outside pregnancy and 3 – 4 min in pregnant women) within one minute;
following intramuscular administration, (a maximum of 10 IU) it occurs within 3 – 5
minutes [95 ].
6.1.2 Carbetocin
The therapeutic use of carbetocin to treat PPH is an off-label use, as it has
currently not yet been sufficiently validated in studies. The administration of
carbetocin to treat PPH has been reported in individual cases.
6.1.3 Methylergometrine
Consensus-based recommendation 6.E3
Expert consensus
Level of consensus +++
Reference: [26 ]
Because of its range of side effects, methylergometrine should not be used
to manage postpartum bleeding as other alternatives are available in
Europe.
6.1.4 Prostaglandins
Consensus-based recommendation 6.E4
Expert consensus
Level of consensus +++
References: [26 ], [96 ], [97 ], [98 ]
If first-line uterotonic drugs fail or the patient does not respond,
medication must be switched without delay to prostaglandins. The use of
sulprostone is recommended because of its favourable efficacy profile and
relatively limited side effects.
Consensus-based recommendation 6.E5
Expert consensus
Level of consensus +++
References: [26 ], [99 ]
Oxytocin receptor agonists and prostaglandins should not be administered at
the same time. If a rapid transition from oxytocin receptor agonists to
sulprostone is necessary for clinical reasons, the cardiovascular side
effects should be carefully monitored.
If first-line uterotonic drugs fail or the patient does not respond to them,
medication must be switched to prostaglandins without delay; it is not necessary to
observe a time gap/pause (particularly when administering carbetocin) between
medications.
6.1.4.1 Sulprostone
Consensus-based recommendation 6.E6
Expert consensus
Level of consensus +++
Reference: [26 ]
Sulprostone must be exclusively administered intravenously (infusion
pump/syringe driver). Because it is difficult to control, intramuscular or
intramyometrial administration must be avoided.
The following de-escalating regimen to administer sulprostone has been found to be
useful for the clinical management of PPH (recommendation of the guideline
authors):
6.1.4.2 Misoprostol
Consensus-based statement 6.S1
Expert consensus
Level of consensus +++
Reference: [26 ]
Because of its delayed onset of action and the availability of better
approved alternatives, misoprostol is not suitable for the treatment of
persistent PPH.
The use of misoprostol may be considered (off-label use!) to treat moderately
persistent PPH after administering oxytocin; however, the current data are not
sufficient to permit a final recommendation to be made.
6.1.4.3 Intrauterine administration of prostaglandins
Consensus-based recommendation 6.E7
Expert consensus
Level of consensus +++
References: [26 ], [97 ]
Sulprostone must not be administered by intramyometrial or intracervical
application.
6.2 Antifibrinolytic drugs (tranexamic acid)
Consensus-based recommendation 6.E2
Expert consensus
Level of consensus +++
References: [100 ], [101 ], [102 ]
After PPH is diagnosed, tranexamic acid 1 g IV must be administered at the
same time as oxytocin receptor agonists are administered, without a prior
coagulation analysis. The earlier tranexamic acid is administered, the more
effective it will be.
7 Uterine tamponade
In addition to other second-line treatment strategies, uterine tamponade may
significantly reduce the rate of emergency hysterectomies [103 ], [104 ], [105 ].
Different balloon systems (approved systems: Bakri balloon, ebb Complete Tamponade
System) are available for uterine tamponade, in addition to tamponade strips. Their
efficacy has been confirmed in different publications and they offer the advantage
that
persistent bleeding is recognised early [105 ], [106 ], [107 ], [108 ], [109 ], [110 ], [111 ], [112 ], [113 ], [114 ], [115 ].
There have been several recent case series reporting on the use of gauze (Celox) coated
with a haemostatic agent (chitosan), originally developed for emergency and military
medicine, as an intrauterine tamponade to manage PPH. The use of this type of gauze
should
be preferred to a simple gauze tamponade, especially for anticoagulation [116 ] – [118 ]. In November
2022, the manufacturer reported that Celox PPH, a special variant of Celox, was CE
certified.
In recent years, more reports on the use of uterine packing, i.e., uterine tamponade
with
gauze have been published [105 ], [107 ], [119 ]. Potential
drawbacks include possible occult bleeding as well as bleeding on removal and,
potentially, pain when removing the tamponade.
Vacuum-induced uterine tamponade is a method which has not yet been widely used in
German-speaking countries [120 ] – [126 ].
A combination of different tamponade methods with uterine compression sutures, similar
to
a “sandwich technique,” have been successfully used in different case series [127 ], [128 ], [129 ], [130 ].
Consensus-based recommendation 7.E1
Expert consensus
Level of consensus +++
References: [106 ], [112 ], [127 ], [131 ], [132 ], [133 ]
Uterine tamponade, irrespective of the chosen method, does not exclude the use
of other potentially necessary therapeutic options such as compression sutures;
they are urgently recommended when treating atony.
8 Surgical measures
8.1 Bridging interdisciplinary measures
In the event of the lethal triad of persistent bleeding, haemorrhagic shock and
coagulopathy, the recommended approach must be damage control surgery, carried out
in
three stages [134 ], [135 ]:
Surgical haemostasis carried out within an acceptable time frame using a
Pfannenstiel incision or median laparotomy, eventration of the uterus with cranial
traction and uterine compression and atraumatic clamping of the uterine arteries to
minimise perfusion. Placement of uterine compression sutures and application of a
uterine tamponade.
In parallel, anaesthetic and intensive care measures performed to correct
hypovolaemia, hypothermia, acidosis and coagulopathy; if necessary, surgery must be
paused until the patient is stable.
Definitive (surgical) treatment of the now haemodynamically stabilised patient by
a
surgeon with the appropriate surgical expertise. If the infrastructure is available,
one option may be interventional radiological embolization of the afferent uterine
arteries [136 ], [137 ].
Consensus-based recommendation 8.E1
Expert consensus
Level of consensus +++
References: [135 ], [138 ], [139 ], [140 ], [141 ]
Bimanual compression of the aorta for up to 20 minutes may be carried out
during the “bridging period” to avoid unnecessary loss of blood. If it is
foreseeable that the bleeding cannot be controlled by a hysterectomy or if the
bleeding continues despite performing a hysterectomy, packing of the pelvis
and abdomen should be carried out using a sufficient number of moistened
abdominal bandages. If interventional radiological measures can be carried
out, temporary balloon occlusion of the aorta may be performed.
8.2 Compression sutures
Consensus-based recommendation 8.E2
Expert consensus
Level of consensus +++
Reference: [26 ]
Appropriate suturing materials (large needle, long sutures) must be kept on
hand in operating rooms for uterine compression sutures.
In the last 15 years, the range of surgical treatment options has been significantly
expanded by the use of uterine compression sutures [142 ]. This method aims to compress the uterus and reduce the size of the
placental adhesion surface, creating a tamponade at the bleeding site.
It is currently not possible to make a statement about the optimal efficacy of any
specific method; a suitable suturing technique should be used according to the
indication (atony, bleeding from the placental bed, diffuse bleeding) [26 ], [143 ].
8.3 Vascular ligations
In addition to simple ligation of the uterine artery, stepwise uterine
devascularisation may also be carried out. This technique consists of five consecutive
steps to ligate the ascending and descending branches of the uterine arteries and
collateral branches of the ovarian artery [144 ], [145 ].
Consensus-based recommendation 8.E3
Expert consensus
Level of consensus +++
Reference: [26 ]
Ligation of the internal iliac artery must only be carried out as an ultima
ratio and only by a surgeon with extensive experience of pelvic surgery.
8.4 Postpartum hysterectomy
Consensus-based recommendation 8.E4
Expert consensus
Level of consensus +++
References: [26 ], [146 ], [147 ]
Conservative measures to preserve the uterus are only reasonable as long as
the patient is haemodynamically stable and bleeding is not life-threatening.
If a hysterectomy is necessary, the decision should not be delayed.
Consensus-based recommendation 8.E5
Expert consensus
Level of consensus +++
Reference: [26 ]
Supracervical hysterectomy should be preferred in cases with atony as the
operating time is significantly shorter and it does not result in unintended
shortening of the vagina. Total hysterectomy may be considered in cases with
placental implantation disorders or cases with injuries of the lower uterine
segment; imaging of the ureters is recommended in these cases.
Relative contraindications for uterus-preserving measures include:
extensive placental implantation disorders (placenta increta/percreta) where the
placental implantation bed is open, bleeding at the placental implantation bed does
not respond to therapy or the placental implantation bed covers large areas of the
uterine wall,
non-reconstructable uterine injury,
septic uterus.
9 Interventional radiological procedures: transarterial techniques
temporary/intermittent balloon occlusion of the iliac arteries
temporary/intermittent balloon occlusion of the aorta
embolization of the uterine arteries
Consensus-based recommendation 9.E1
Expert consensus
Level of consensus +++
Reference: [26 ]
Every obstetric department must ascertain which interventional radiological
procedures are available to treat PPH. If these procedures can be carried out
in-house or locally, an appropriate interdisciplinary treatment pathway should
be agreed on, which will include the use of interventional radiological
techniques at an early stage after conservative measures have been
exhausted.
Consensus-based recommendation 9.E2
Expert consensus
Level of consensus +++
Reference: [26 ]
If a radiological procedure/treatment is indicated, the radiology department
should be informed early on (e.g., if haemostasis is unsuccessful after placing
uterine compression sutures).
Consensus-based recommendation 9.E3
Expert consensus
Level of consensus ++
Reference: [26 ]
Other treatment options should be largely exhausted prior to carrying out
interventional radiological treatment.
Consensus-based recommendation 9.E4
Expert consensus
Level of consensus +++
Reference: [26 ]
If the procedure can be planned (e.g., in cases with placenta accreta
spectrum), vascular access and placement of the occlusion balloon may already be
carried out preoperatively.
10 Haemostasis and coagulation management
10.1 Background
Consensus-based statement 10.S1
Expert consensus
Level of consensus +++
Reference: [26 ]
The leading causes of PPH are atony, traumatic injury, placental remnants,
and coagulation disorders. It is rare for a primary coagulation disorder
(coagulopathy) to be the cause of PPH. The coagulopathy is usually acquired
during PPH ([Fig. 2 ]).
Fig. 2 Pathophysiology of obstetric coagulopathy [26 ]. [rerif]
According to the concept of the 4 Tʼs, atony, placental retention, and vascular lesions
accompanied by increased fibrinolytic activity are the most important causes of PPH.
If
early treatment of the cause is unsuccessful, persistent PPH will always result in
a
coagulopathy, irrespective of the original cause [148 ], [149 ], [150 ].
The larger the volume of replacement fluids, the worse the coagulation parameters
will
be [151 ]. Orientating perioperative levels for
haemodynamic stability are BE > −6 mEq/l, lactate < 4 mmol/l and pCO2
gap < 6 mmHg [152 ].
Consensus-based recommendation 10.E1
Expert consensus
Level of consensus +++
References: [26 ], [91 ], [153 ], [154 ], [155 ], [156 ]
All hospitals with obstetric departments must develop a treatment algorithm
for the peripartum/postpartum period which is adapted to the conditions in the
respective hospital. The focus must be on early diagnosis and the targeted
treatment of bleeding. The algorithm must define the approach used for
treatment and include all available treatment options including
pharmacological, haemostatic, radiological interventions, and surgical
measures.
10.2 Options to treat peri-/postpartum coagulopathic bleeding
Consensus-based recommendation 10.E2
Expert consensus
Level of consensus +++
Reference: [26 ]
In cases with active bleeding, iatrogenic aggravation of the tendency to
bleed must be avoided, e.g., artificial colloidal volume replacement solutions
should be avoided, as they have a strong dilutional and coagulopathic
effect.
Consensus-based statement 10.S2
Expert consensus
Level of consensus +++
Reference: [26 ]
Standard haemostatic therapy to treat severe peripartum bleeding consists of
the early administration of tranexamic acid, coagulation factor concentrates
and/or fresh frozen plasma with coagulation factors (FFP) to avoid an
additional dilutional coagulopathy in addition to the ongoing loss of
blood.
Consensus-based recommendation 10.E3
Expert consensus
Level of consensus +++
References: [26 ], [91 ]
In cases with persistent bleeding, evidence of a lack of coagulation factors
is useful to determine the appropriate targeted therapy. Evidence for
coagulation factor deficiencies should be obtained from laboratory parameters
(e.g., hemogram, blood gas analysis [BGA], aPTT, Quick or INR and, if
available, fibrinogen, factor XIII, and viscoelastic tests [VET]).
In addition to primary haemostasis, recent data have shown that when treating patients
with peripartum bleeding, in addition to fibrinogen [37 ], [91 ], the focus must also be on other
components of the final steps of the coagulation pathway [157 ], [158 ]. It is important to ensure a
balanced replacement of all components involved in cases with a specifically identified
or anticipated deficiency (justifiable targets: FXIII > 60% [157 ], [158 ], platelets
70 – 100 Gpt/l [159 ], fibrinogen > 2 – 2.5 g/l [160 ], [161 ], [162 ]).
Consensus-based recommendation 10.E4
Expert consensus
Level of consensus +++
References: [26 ], [37 ], [91 ]
To begin with, any existing increased fibrinolytic activity must be treated
by the administration of tranexamic acid (antifibrinolytic agent) before
administering procoagulant factors (platelets, fibrinogen, FXIII, PPSB).
For dosage recommendations, see recommendation 10.E6.
Consensus-based recommendation 10.E5
Expert consensus
Level of consensus ++
References: [26 ], [91 ], [154 ], [155 ], [159 ], [163 ], [164 ], [165 ], [166 ], [167 ], [168 ], [169 ]
* Note: After the procedure to achieve consensus had been concluded/AWMF
guideline 015/063 had been submitted, the official approval for recombinant
Factor VIIa (rFVIIa) was expanded to include its use to treat “severe
postpartum bleeding when uterotonic drugs are not sufficient to achieve
haemostasis”. In this expanded official approval, the use of rFVIIa was
proposed for patients who failed to respond to sulprostone, with a proposed
rFVIIa dosage of 60 – 90 µg/kg; this should take effect within 10 minutes; a
possible second dose may be administered after 30 minutes [170 ]. Without postponing the publication date of
the guideline, the guidelines commission was unable to evaluate all of the
published data on the use of rFVIIa in patients with severe PPH who do not
respond to uterotonic drugs. The decision was therefore taken not to change
the current recommendation regarding the use of rFVIIa as a last resort for
patients with severe refractory PPH who do not respond to all other treatment
options, and to evaluate the literature on the use of rFVIIa in any subsequent
revision of the guideline.
Recommendations for the haemostatic management of persistent PPH requiring
substitution are:
a treatment concept adapted to the specific conditions in the respective
hospital
restoring or securing the conditions for coagulation
temperature (> 34 °C)
calcium (> 0.9 mmol/l)
pH (> 7.2)
administration of tranexamic acid immediately after diagnosing PPH
fresh frozen plasma (FFP) for plasma volume replacement
targeted coagulation therapy carried out in parallel to surgical,
mechanical and supplementary measures:
For dosage recommendations, see recommendation 10.E6.
There are currently no reliable data which would permit an evidence-based
recommendation to be made on the use of DDAVP (desmopressin) in obstetrics as an acute
therapy to treat bleeding [171 ], even though a positive
effect has been repeatedly observed [172 ].
DDAVP must only be administered under the following conditions [26 ]:
only for thrombopathies known to respond to DDAVP (consultation with the
haemostasiology department recommended!)
not to patients with known “sub”-haemophilia A (i.e., carriers for
haemophilia A)
not to patients known to have von Willebrand syndrome type 1
after umbilical cord clamping and cutting
Consensus-based recommendation 10.E6
Expert consensus
Level of consensus ++
Reference: [26 ]
1
Stabilisation of the patientʼs general condition (prophylaxis
and
therapy!)
Core temperature ≥ 34 °C (ideally normothermia )
pH ≥ 7.2
ionised Ca++ concentration > 0.9 mmol/l (ideally
normocalcemia )
2
Inhibition of potential hyper-fibrinolytic activity (always
before
administering fibrinogen and/or fresh frozen plasma)
Tranexamic acid initially 1 g
If needed, one repeat dose
3
Substitution of oxygen carriers
RBC administration
haemostatic goal in cases with severe bleeding: Hb ca.
7 – 9 g/dl (4.3 – 5.5 mmol/l)
4
Substitution of coagulation factors (for persistent increased bleeding
tendency) depending on availability in the hospital
Patients who (will) require massive transfusions or who are suffering from
haemorrhagic life-threatening shock may benefit from a high ratio of
FFP : RBC : PC, for example, 4 (to 6) to 4 (to 6) to 1, or combined
administration of plasma and factor concentrates as well as platelet
concentrates
Fibrinogen 30 – 60 mg/kg BW , goal: ≥ 2 – 2.5 g/l
and
FXIII 20 IU/kg BW , goal: FXIII activity > 60%
or FFP ≥ 30 ml/kg BW
or PPSB initially 25 IU/kg BW
5
Replace plasma volume
FFP ≥ 30 ml/kg BW
6
Platelet substitution for primary haemostasis
Platelet concentrates (for persistent bleeding requiring transfusion ;
goal: ≥ 70 – 100 Gpt/l )
7
If necessary, a “thrombin burst” with platelet and coagulation activation
(consider haemostatic conditions!)
In individual cases:
ggf. rFVIIa initial 60(– 90) µg/kg BW
Caution:
no antithrombin or heparin during bleeding
thrombosis prophylaxis is mandatory (!) within 24 hours after
cessation of the pathology which caused the bleeding
possibly DDAVP (desmopressin) 0.3 µg/kg BW for 30 min (in cases
with [suspected] acquired thrombocytopenia – only after clamping and
cutting )
Consensus-based statement 10.S2
Expert consensus
Level of consensus +++
References: [26 ], [37 ], [173 ]
There is an increased risk of thromboembolism after haemostasis due to
reduced antithrombin activity (in some instances, absolute activity < 50%).
This necessitates thrombosis prophylaxis within 24 hours; in cases with risk
factors, thrombosis prophylaxis should be continued for up to 6 weeks
postpartum.
Consensus-based recommendation 10.E7
Expert consensus
Level of consensus +++
References: [174 ], [175 ], [176 ]
Antithrombin activity may be determined in the intensive care unit and
substitution may be considered after cessation of bleeding, especially after
administering concentrates of individual coagulation factors or complex
preparations (especially PPSB).
10.3 Anaesthesia-related aspects of managing PPH
Consensus-based recommendation 10.E8
Expert consensus
Level of consensus +++
Reference: [26 ]
A timely call for expert assistance should be considered when blood loss is
more than 1000 ml and expert assistance must be called in when persistent
blood loss is 1500 ml.
Consensus-based recommendation 10.E9
Expert consensus
Level of consensus +++
Reference: [26 ]
Haemodynamic stability must be maintained or achieved during PPH. Needs-based
volume replacement therapy must be carried out with careful monitoring of
volumes to avoid iatrogenic over-infusion. The haemodynamic response to the
administered fluid volume must be monitored.
Consensus-based recommendation 10.E10
Expert consensus
Level of consensus +++
References: [26 ], [177 ]
Secure the airways and ensure a sufficient oxygen supply to patients
receiving regional anaesthesia (spinal anaesthesia, epidural anaesthesia):
early intubation should be considered for a blood loss of ≥ 1500 ml with signs
of persistent bleeding. If there is a loss of protective reflexes,
endotracheal intubation to secure the airways and ensure a sufficient oxygen
supply must take priority.
Consensus-based recommendation 10.E11
Expert consensus
Level of consensus +++
References: [26 ], [177 ], [178 ], [179 ], [180 ]
Large-lumen access points (2 × ≥ 16 G) must be placed; arterial blood
pressure measurement should be carried out as a secondary measure, if needed;
when in doubt, create a wide-lumen central (≥ 9 Fr) access and use a massive
transfusion unit.
Consensus-based recommendation 10.E12
Expert consensus
Level of consensus +++
References: [26 ], [181 ]
After cessation of bleeding, intravenous (or oral) iron substitution may be
carried out according to local conditions to compensate for the iron
deficiency as evidenced by laboratory analysis (soluble transferrin receptor
or ferritin < 100 ug/l and transferrin saturation < 20%) or decreased
haemoglobin levels (< 9.5 g/dl).
10.3.1 Mechanical autotransfusion (MAT) for PPH
Consensus-based recommendation 10.E13
Expert consensus
Level of consensus +++
Reference: [26 ]
Mechanical autotransfusion should be considered for patients with increased
risk of bleeding.
National recommendations and international guidelines recommend mechanical
autotransfusion for patients with severe PPH (CMACE, NICE, OAA/AAGBI, ESAIC).
Only after amniotic fluid has been suctioned and the infant has been delivered
[182 ].
Initially, only “collect” (i.e., create a reservoir); carry out “washing” if
needed (i.e., additional suction system with tubing); in such cases, standard use
of autotransfusion may also be cost-effective [183 ], [184 ].
Auto-transfused blood contains no coagulation factors or platelets; coagulation
factors should be substituted to avoid coagulopathy following high transfusion
volumes [185 ].
Use of leukocyte depletion filters has been recommended based on theoretical
considerations. Recent studies do not consider this to be necessary [183 ], [184 ], [186 ].
Standard use of autotransfusion in all caesarean section results in
re-transfusion volumes of around 250 ml [183 ], [184 ]; the use of autotransfusion
can therefore only be recommended for patients with a high risk of bleeding.
We recommend obtaining a guarantee from the respective manufacturer of the device
that the unit will wash out tissue-factor-containing amniotic fluid/placental
tissue.
10.4 Benefit of diagnostics using a point-of-care (PoC) approach and standard lab
tests for coagulation analysis
Consensus-based statement 10.S3
Expert consensus
Level of consensus +++
Reference: [26 ]
Treatment with coagulation factors or platelets is indicated for patients
with persistent severe peripartum bleeding (> 1500 ml) and evidence for a
deficiency of coagulation factors or platelets.
Time plays an essential role in the diagnosis and treatment of PPH [187 ]. A deficiency of one or more coagulation factors can be
diagnosed with parameters obtained by standard coagulation laboratory tests and
viscoelastic tests (VET). However, standard laboratory/VET values are mainly useful
to
decide when substitution is not required [188 ]. The
preventive administration of fibrinogen is not useful, not even in an obstetric setting
[189 ].
11 Treatment algorithms
11.1 Atony
Anticipate risk factors
Diagnosis: increased fundal height; soft, relaxed uterus; usually intermittent
surge-like bleeding
Empty the bladder!
Mechanical procedures: uterine massage (endogenous prostaglandin formation),
bimanual uterine compression (e.g., Hamiltonʼs procedure)
Caution:
500 – 1000 ml of blood may collect in the uterine cavity → discrepancy between
externally apparent level of bleeding and development of a serious loss of volume.
In cases of uncertainty, attempt rapid clarification using ultrasound as long as
this does not lead to delay
Exclude birth trauma (speculum examination and abdominal US, if necessary)
Exclude placental remnants (check placenta for completeness, ultrasound)
Consensus-based recommendation 11.E1
Expert consensus
Level of consensus +++
Reference: [26 ]
Treatment plan for atony:
uterotonic drugs, tranexamic acid if necessary
if placental remnants are present: curettage in the labour room or the
operating room
uterine tamponade if necessary
additional surgical measures
poss. embolization/balloon occlusion
11.2 Placenta accreta spectrum
Anticipate risk factors (previous uterine surgery/curettage); in patients with
prenatal suspicion of placentation disorder → care by a multidisciplinary team
The management of placental detachment disorders depends on the time of diagnosis
and the mode of delivery.
Early interdisciplinary discussion/treatment plan is advisable.
Consensus-based statement 11.S1
Expert consensus
Level of consensus +++
References: [26 ], [190 ], [191 ], [192 ]
Important cornerstones when managing PAS!
The treatment plan of a pregnant woman with PAS includes:
constant access to blood products at short notice
contingency to carry out complex pelvic surgery
multidisciplinary team
review case (repeatedly if necessary) with members of the team (the
pregnant woman must be known; an individual treatment plan must be set
up)
24-h availability of interdisciplinary surgical intensive care for the
mother and a neonatology intensive care unit
If these conditions cannot be met: the pregnant woman must be presented to a
suitable centre.
Consensus-based recommendation 11.E2
Expert consensus
Level of consensus +++
Reference: [26 ]
Management recommendations for PAS:
Multidisciplinary team with best possible expertise
Multidisciplinary planning of the birth prepartum (elective caesarean
section if possible)
Ensure sufficient blood products/coagulation
factors/
Management for elective delivery:
Place adequate intravenous access points, volume substitution
Place access points and occlusion balloon already preoperatively if
necessary
Laparotomy (longitudinal incision if necessary)
Hook out the uterus if necessary
Devascularisation of afferent vessels and dissection of the uterus from
the bladder
Intraoperative ultrasound if necessary to obtain the exact location of
the placenta and position the uterotomy (at a sufficient distance to the
placenta – transversely to the fundus)
Delivery of the infant/cutting and clamping of the cord (caution: no
traction on the placenta)
Administer uterotonic drugs and tranexamic acid IV
Ideally do not attempt to separate the placenta (risk of bleeding) – at
most, if the situation is not clear (suspected PAS), carefully attempt to
manually separate the placenta
Individualised surgical procedure if necessary
Autotransfusion in cases with high loss of blood
Continuous antibiotic prophylaxis
No administration of methotrexate
11.2.1.1 Extensive findings
11.2.1.2 Focal findings
Partial resection of the uterine wall while retaining the uterus in cases with
locally limited implantation disorder.
Focal intracavitary Z-sutures to achieve haemostasis in small areas of
bleeding.
Interventional radiology if necessary: prophylactic occlusion of the internal
iliac arteries [193 ], [194 ].
11.2.2 Management following antenatal diagnosis
Consensus-based recommendation 11.E3
Expert consensus
Level of consensus +++
Reference: [26 ]
Pregnant women with suspected PAS (with/without placenta praevia) must be
delivered in a perinatal centre with the relevant interdisciplinary
expertise in managing PAS. Prenatal early presentation of the patient to the
centre is strongly recommended.
11.2.3 Management with intrapartum diagnosis
11.2.3.1 Vaginal birth
In cases where the placenta fails to detach and bleeding is present → ultrasound
evaluation and manual separation of the placenta, followed by curettage with
intraoperative ultrasound monitoring, if necessary.
If severe bleeding from the placental bed persists → surgical treatment;
alternatively, embolization of the uterine arteries.
11.2.3.2 Caesarean section
Consensus-based recommendation 11.E4
Expert consensus
Level of consensus +++
Reference: [26 ]
If diagnosed intraoperatively and mother and child are stable, emergency
transportation of the patient to a centre with the relevant expertise
should be considered.
If this is not possible, care by the best experts available must be
ensured without delay.
Do not manipulate the placenta if possible or attempt manual separation of the
placenta!
Perform caesarean section with hysterectomy or alternatively delay delivery of the
placenta (ideally in a centre with 24-h availability of an interdisciplinary
surgical intensive care ward).
11.3 Uterine inversion
Uterine inversion may occur both with vaginal delivery and caesarean section
(caused by the uterotomy).
Vaginal palpation: inverted intravaginal fundus.
Abdominal palpation: no fundal resistance, cuplike invagination may be
palpated.
If the findings are not clear → ultrasound examination [195 ], [196 ].
Consensus-based recommendation 11.E5
Expert consensus
Level of consensus +++
References: [26 ], [197 ], [198 ], [199 ] (For images of the manoeuvres, see [26 ])
The goal is to reposition the uterus and treat the symptoms of haemorrhagic
shock; The following measures must be carried out immediately after diagnosis
and in the order given below:
Stop administration of any uterotonic drugs
Call in experienced obstetrician and anaesthesiologist
Ensure adequate intravenous access, volume substitution
Do not attempt to separate the placenta; because of the increased loss of
blood, the placenta must, if possible (placenta accreta), only be
delivered after repositioning.
Attempt to reposition the fundus (Johnsonʼs manoeuvre)
Consider general anaesthesia with the aim of relaxing the uterus
If the attempt at repositioning fails, administer uterine relaxants
(e.g., nitroglycerin 50 µg IV or hexoprenaline 10 µg IV) and carry out a
new repositioning attempt using Johnsonʼs manoeuvre
If the repositioning attempt continues to be unsuccessful → perform
laparotomy and Huntingtonʼs procedure, simultaneously with Johnsonʼs
manoeuvre if necessary; if the attempts are still unsuccessful, perform
the Haultain procedure
Administer uterotonic drugs (e.g., oxytocin) after successful
repositioning
Provide antibiotic protection (e.g., cephalosporin or clindamycin)
12 Transportation
Consensus-based recommendation 12.E1
Expert consensus
Level of consensus +++
References: [26 ], [200 ]
The facility transferring the patient and the facility accepting the patient
should have already agreed on the timing of transportation and staff coverage
during transportation in the run-up to the transfer and the agreement between
the two facilities should be recorded in writing.
Consensus-based recommendation 12.E2
Expert consensus
Level of consensus +++
References: [26 ]
Transportation of a haemodynamically instable patient as part of the management
of PPH should be weighed up carefully and depend on the organisational
conditions in the facility providing care. The patient should preferably only be
transferred after haemodynamic stabilisation.
12.1 Recommendations for managing the interface between non-hospital-based
obstetric care/
Specific plans and arrangements must be agreed upon between the persons/facilities
providing care (home-birth midwife, midwifery-led unit, hospital staff) before an
emergency occurs and developed during joint team meetings or training courses.
Arrangements must include professional exchanges on how the patient will be
transported (who will be informed, how, and by whom) as well as the specific
situation when handing over the patient (how will the patient be handed over and how
will further communications be made).
A joint approach to the transportation of patients should be agreed upon beforehand
and should be communicated to the relevant regional institutions beforehand,
including to the rescue coordination centre (description of procedures, emergency
telephone numbers, contact persons).
Jointly agreed terms, for example: “Acute danger to life of mother and/or child”,
the specific diagnosis (e.g., placental abruption, PPH), “Please inform on-call
consultants and staff”, “Please ensure the operating team is in readiness”, etc.,
ensure that communications will be effective and make it easier for the hospital to
prepare for the emergency.
Carry out a joint case review after an emergency which includes all persons
providing care during the emergency to continually improve and optimise cooperation
between non-hospital-based and hospital-based obstetric care as part of improving
patient safety.
13 Monitoring after PPH
Consensus-based recommendation 13.E1
Expert consensus
Level of consensus +++
References: [26 ], [201 ], [202 ]
After a PPH, individually adapted monitoring must be carried out.
14 Documentation
Consensus-based recommendation 14.E1
Expert consensus
Level of consensus +++
Reference: [26 ]
Careful documentation of every event defined as an emergency is essential. The
use of special forms developed for the respective organisational unit is
recommended.
15 Debriefing
Consensus-based recommendation 15.E1
Expert consensus
Level of consensus +++
Reference: [26 ]
After PPH, the affected patient and her companion(s) must be offered a
follow-up discussion using language comprehensible to non-medical specialists.
The discussion must include a member of the obstetric team if necessary and be
held in the first days postpartum. It should be documented for the patientʼs
further outpatient care. The patient must be informed that the offer to have a
discussion will hold good even after she has been discharged from hospital.
Consensus-based statement 15.S1
Expert consensus
Level of consensus +++
Reference: [26 ]
Interdisciplinary debriefing of the team is recommended.
Consensus-based recommendation 15.E2
Expert consensus
Level of consensus +++
References: [26 ]
A crisis intervention option should be available for the team; this applies
particularly in cases where the outcome was fatal.
16 Training
Consensus-based recommendation 16.E1
Expert consensus
Level of consensus +++
References: [26 ], [203 ], [204 ], [205 ]
Structured simulations of peripartum haemorrhage and appropriate responses by
an interdisciplinary team should be carried out regularly to improve the teamʼs
technical und non-technical skills.
