Patient presents with blood loss >1000 mL, or blood loss accompanied by signs and symptoms of hypovolemia, within 24 hours of delivery
Is the patient hemodynamically stable?
The American College of Obstetricians and Gynecologists (ACOG) defines maternal hemorrhage as cumulative blood loss >1000 mL or blood loss accompanied by signs and symptoms of hypovolemia, occurring within 24 hours after delivery. Other organizations, including the World Health Organization, use a more conservative definition of postpartum hemorrhage as >500 mL of blood loss within 24 hours after delivery, or differentiate by delivery type, setting thresholds of 500 mL for vaginal delivery and 1000 mL for cesarean delivery. ACOG recommends the use of objective methods to quantify blood loss, such as weighing blood-soaked drapes or using calibrated obstetric drapes. Visual methods of estimation have been shown to consistently underestimate blood loss.
In recent decades, the rate of death related to postpartum hemorrhage has decreased in the United States, most likely due to increased use of interventions such as blood transfusion and postpartum hysterectomy. However, postpartum hemorrhage requiring transfusion of blood products remains the leading cause of maternal morbidity in the United States, closely followed by disseminated intravascular coagulation (DIC). Early recognition of unexpected heavy bleeding in the postpartum period allows for early intervention, which is critical to the reduction of maternal complications. A postpartum patient may not show signs and symptoms of significant blood loss (eg, tachycardia and hypotension) until approximately 25% of total blood volume has been lost, and exclusive reliance on abnormal vital signs for identification of postpartum hemorrhage may delay treatment.
- United States Centers for Disease Control and Prevention. Preventing Pregnancy-Related Deaths. Accessed September 1, 2021. (Informational website)
- United States Centers for Disease Control and Prevention. Pregnancy Mortality Surveillance System. Accessed September 1, 2021. (Surveillance data)
- The Joint Commission. Provision of care, treatment, and services standards for maternal safety. R3 Report: Requirement, Rationale, Reference. 2019(24):1-6. (Rationale statement)
- Practice Bulletin No. 183: postpartum hemorrhage. Obstet Gynecol. 2017;130(4):e168-e186. (Practice guideline)
- World Health Organization. WHO Recommendations for the Prevention and Treatment of Postpartum Haemorrhage. Accessed September 1, 2021. (Practice guideline)
- Quantitative blood loss in obstetric hemorrhage: ACOG Committee Opinion Summary, Number 794. Obstet Gynecol. 2019;134(6):1368-1369. (Practice guideline)
- Creanga AA, Berg CJ, Ko JY, et al. Maternal mortality and morbidity in the United States: where are we now? J Womens Health (Larchmt). 2014;23(1):3-9. (Review)
- Anderson JM, Etches D. Prevention and management of postpartum hemorrhage. Am Fam Physician. 2007;75(6):875-882. (Practice recommendations)
- Kandeel M, Sanad Z, Ellakwa H, et al. Management of postpartum hemorrhage with intrauterine balloon tamponade using a condom catheter in an Egyptian setting. Int J Gynaecol Obstet. 2016;135(3):272-275. (Prospective observational study; 151 patients)
- Darwish AM, Abdallah MM, Shaaban OM, et al. Bakri balloon versus condom-loaded Foley’s catheter for treatment of atonic postpartum hemorrhage secondary to vaginal delivery: a randomized controlled trial. J Matern Fetal Neonatal Med. 2018;31(6):747-753. (Randomized controlled trial; 66 patients)
- Rathore AM, Gupta S, Manaktala U, et al. Uterine tamponade using condom catheter balloon in the management of non-traumatic postpartum hemorrhage. J Obstet Gynaecol Res. 2012;38(9):1162-1167. (Prospective study; 18 patients)
- Tindell K, Garfinkel R, Abu-Haydar E, et al. Uterine balloon tamponade for the treatment of postpartum haemorrhage in resource-poor settings: a systematic review. BJOG. 2013;120(1):5-14. (Literature review; 13 studies, 241 patients)
- Tranexamic Acid - Drug Summary. Prescribers' Digital Reference. Accessed September 1, 2021. (Medication package insert)
- Gestational hypertension and pre-eclampsia: ACOG Practice Bulletin, Number 222. Obstet Gynecol. 2020;135(6):e237-e260. (Practice guideline)
- Vermillion ST, Scardo JA, Newman RB, et al. A randomized, double-blind trial of oral nifedipine and intravenous labetalol in hypertensive emergencies of pregnancy. Am J Obstet Gynecol. 1999;181(4):858-861. (Randomized double-blind trial; 50 patients)
- Raheem IA, Saaid R, Omar SZ, et al. Oral nifedipine versus intravenous labetalol for acute blood pressure control in hypertensive emergencies of pregnancy: a randomised trial. BJOG. 2012;119(1):78-85. (Randomized double-blind trial; 50 patients)
- Bateman BT, Patorno E, Desai RJ, et al. Late pregnancy blocker exposure and risks of neonatal hypoglycemia and bradycardia. Pediatrics. 2016;138(3):e20160731. (Retrospective cohort; 10,585 patients)
- Magee LA, Miremadi S, Li J, et al. Therapy with both magnesium sulfate and nifedipine does not increase the risk of serious magnesium-related maternal side effects in women with pre-eclampsia. Am J Obstet Gynecol. 2005;193(1):153-163. (Retrospective chart review; 377 patients)
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Maternal Hemorrhage and Severe Hypertension/Pre-eclampsia: Identification and Management in the Emergency Department