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Prevention and Management of Postpartum Hemorrhage: A Comparison of Four National Guidelines

Dahlke JD et al.

Am J Obstet Gynecol. 2015 Feb 27. pii: S0002-9378(15)00159-3. doi: 10.1016/j.ajog.2015.02.023.

Editor’s comment: Prof. Jim Thornton: Management of post- partum hemorrhage
Guidelines for management of post- partum haemorrhage from the American College of Obstetrician and Gynecologists (ACOG), Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZOG), Royal College of Obstetrician and Gynaecologists (RCOG), and Society of Obstetricians and Gynaecologists of Canada (SOGC) all recommend oxytocin for primary prevention in vaginal deliveries. But recommendations about active management of the third stage, massive transfusion protocols, and non-surgical treatment strategies vary.  

Abstract
Objective

To compare four national guidelines for the prevention and management of postpartum hemorrhage (PPH).

Study Design
We performed a descriptive analysis of guidelines from the American College of Obstetrician and Gynecologists (ACOG) practice bulletin, Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZOG), Royal College of Obstetrician and Gynaecologists (RCOG), and Society of Obstetricians and Gynaecologists of Canada (SOGC) on PPH to determine differences, if any, with regard to definitions, risk factors, prevention, treatment, and resuscitation.

Results
PPH was defined differently in all four guidelines. Risk factors emphasized in the guidelines which conferred a high risk of catastrophic bleeding (e.g. previous cesarean delivery and placenta previa). All organizations except ACOG recommended active management of the third stage of labor (AMTSL) for primary prevention of PPH in all vaginal deliveries. Oxytocin was universally recommended as the medication of choice for PPH prevention in vaginal deliveries. RANZOG and RCOG recommended development of a massive transfusion protocol to manage PPH resuscitation. Recommendations for non-surgical treatment strategies such as uterine packing, and balloon tamponade varied across all guidelines. All organizations recommended transfer to a tertiary care facility for suspicion of abnormal placentation. Specific indications for hysterectomy were not available in any guideline, with RCOG recommending hysterectomy ‘sooner rather than later’ with the assistance of a second consultant.

Conclusion
Substantial variation exists in postpartum hemorrhage prevention and management guidelines among four national organizations, highlighting the need for better evidence and more consistent synthesis of the available evidence with regard to a leading cause of maternal mortality.

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Commentaries by Editor Prof. Jim Thornton