Comparison of postpartum haemorrhage guidelines: discrepancies underline our lack of knowledge

FIGO consensus guidelines on placenta accreta spectrum disorders: Conservative management,

“…This procedure consists of forcibly removing the placenta manually in an attempt to empty the uterus at delivery. The aim of this approach is to avoid leaving retained placental tissues in the uterine cavity and it is recommended by established worldwide guidelines as one of the first steps to manage postpartum hemorrhage . However, in cases of PAS disorders, this procedure often results in massive obstetric hemorrhage and, overall, not disturbing the accreta portion of the placenta is associated with more than a 50% reduction in blood loss and need for transfusions …”

“…The aim of this approach is to avoid leaving retained placental tissues in the uterine cavity and it is recommended by established worldwide guidelines as one of the first steps to manage postpartum hemorrhage. [6][7][8][9][10][11][12][13] However, in cases of PAS disorders, this procedure often results in massive obstetric hemorrhage and, overall, not disturbing the accreta portion of the placenta is associated with more than a 50% reduction in blood loss and need for transfusions. 13 A retrospective study comparing two consecutive periods of PAS disorder management in a single center found a reduction in the mean amount of red blood cells transfused, disseminated intravascular coagulation, hysterectomy rates, and secondary maternal infection during the second period when the placenta was left in situ compared with the first period when the placenta was always removed manually.…”

Maternal outcome after abdominal packing for uncontrolled postpartum hemorrhage despite peripartum hysterectomy

“…Uterine-sparing surgical procedures to control severe PPH include vessels ligation (uterine and/or internal iliac arteries, stepwise uterine devascularization) and uterine compression sutures (B-Lynch suture, square) and have success rates range from 60 to 75% [4]. Peripartum hysterectomy for PPH is the ultimate surgical procedure performed immediately or when conservative measures are unsuccessful [5]. …”

Definition of bleeding events in studies evaluating prophylactic antithrombotic therapy in pregnant women: A systematic review and a proposal from the ISTH SSC

“…Primary postpartum hemorrhage (PPH) occurs during the first 24 hours and is more likely to result in maternal morbidity and mortality while secondary PPH refers to hemorrhage 24 hours to 6 weeks after delivery . The definition of primary PPH also varies widely between different national guidelines, including those of the Royal College of Obstetricians and Gynaecologists (RCOG), the American College of Obstetricians and Gynecologists (ACOG), the International Federation of Gynecology and Obstetrics (FIGO), the Society of Obstetricians and Gynecologists of Canada (SOGC), the Royal Australian and New Zealand College of Obstetricians and Gynecologists (RANZCOG), the French College of Gynaecologists and Obstetricians (CNGOF), the Netherlands Society of Obstetrics and Gynecology (NVOG), and the German Society for Gynecology and Obstetrics (DGGG) . The ACOG, DGGG, FIGO, and NVOG guidelines define PPH as blood loss >500 mL for vaginal deliveries and >1000 mL for caesarean deliveries, whereas the RANZOG and CNGOF guidelines do not take into account the mode of delivery, and the RCOG guideline divides PPH into three categories: minor (500 mL to 1 L), moderate (>1 to 2 L) and major (>2 L).…”

“…The ACOG, DGGG, FIGO, and NVOG guidelines define PPH as blood loss >500 mL for vaginal deliveries and >1000 mL for caesarean deliveries, whereas the RANZOG and CNGOF guidelines do not take into account the mode of delivery, and the RCOG guideline divides PPH into three categories: minor (500 mL to 1 L), moderate (>1 to 2 L) and major (>2 L). At the same time, most international guidelines consider the visual estimation of the amount of blood loss as unreliable but do not provide objective tools to measure this loss . Major differences between national guidelines have also been reported concerning the pharmacological treatment of PPH, which further confuses assessment of the severity of PPH.…”