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Management of Postpartum Hemorrhage
Comparative Effectiveness Reviews, No. 151
Investigators: Frances E Likis, DrPH, NP, CNM, FACNM, FAAN, Nila A Sathe, MA, MLIS, Alicia K Morgans, MD, Katherine E Hartmann, MD, PhD, Jessica L Young, MD, MPH, Daphne Carlson-Bremer, DVM, MPVM, PhD, Mavis Schorn, PhD, APRN, CNM, Tanya Surawicz, MPH, and Jeff Andrews, MD.
Author Information and AffiliationsStructured Abstract
Objectives:
To systematically review evidence addressing the management of postpartum hemorrhage (PPH) ), including evidence for the benefits and harms of nonsurgical and surgical treatments, interventions for anemia after PPH is resolved, and effects of systems-level interventions.
Data sources:
We searched the MEDLINE®, Embase, and Cumulative Index to Nursing and Allied Health Literature (CINAHL®) databases for articles published in English since 1990.
Review methods:
We included comparative studies of nonsurgical and surgical interventions to manage PPH published in English from 1990 to November 2014 and conducted in high-resource countries. We also included case series addressing harms of interventions and benefits and harms of procedures and surgeries for PPH, as these interventions are unlikely to be addressed in randomized studies. Two investigators independently screened studies against predetermined inclusion criteria (including study design, country of conduct, and outcomes addressed) and independently rated the quality of included studies. We extracted data into evidence and summary tables and summarized them qualitatively.
Results:
We identified a total of 68 unique studies. Sixty-one studies addressed effectiveness outcomes: none of good quality, 23 fair, and 38 poor. Fifty studies reported harms of interventions for PPH management: 11 good quality and 39 poor. Few studies addressed pharmacologic or medical management, including transfusion for supportive management of ongoing PPH, and evidence is insufficient to comment on effects of such interventions. The success of uterine-sparing techniques, such as uterine balloon tamponade, embolization, uterine compression sutures, and uterine and other pelvic artery ligation, in controlling bleeding without the need for additional procedures or surgeries ranged from 36 to 98 percent. However, these data come from a limited number of studies with a small number of participants. Harms of interventions were diverse and not well understood. Studies suggested an association between recombinant activated factor VIIa and thromboembolic events, but sample sizes were small. Some studies with longer term followup reported adverse effects on future fertility and menstrual changes in women undergoing embolization. Studies also reported need for reoperation after hysterectomy. No study (out of two addressing such interventions) demonstrated benefits associated with transfusion or iron supplementation for anemia after PPH is stabilized. Systems-level interventions had little effect on reducing the incidence or severity of PPH or the need for transfusion or hysterectomy.
Conclusions:
The literature addressing management of PPH comprises predominantly studies of poor quality. Diagnosis of PPH is subjective and management is urgent, often involving rapid and simultaneous initiation of interventions. Therefore, comparing the severity of PPH and trajectory of care across studies is challenging. Further research is needed across all interventions for PPH management.
Contents
- Preface
- Acknowledgments
- Key Informants
- Technical Expert Panel
- Peer Reviewers
- Executive Summary
- Introduction
- Methods
- Results
- Results of Literature Searches
- Description of Included Studies
- KQ1 Effectiveness of Interventions for Management of PPH
- KQ2 Evidence for Choosing One Intervention Over Another and Proceeding to Subsequent Interventions
- KQ3 Harms of Interventions for Management of PPH
- KQ4 Effectiveness of Interventions To Treat Acute Blood Loss Anemia in Women With Stabilized PPH
- KQ5 Effectiveness of Systems-Level Interventions for Management of PPH
- Gray Literature
- Discussion
- References
- Abbreviations and Acronyms
- Appendix A Search Strategies
- Appendix B Screening and Quality Assessment Forms
- Appendix C Excluded Studies
- Appendix D Evidence Tables
- Appendix E Quality/Risk of Bias Ratings
- Appendix F Applicability Tables
- Appendix G Study Design Classification Algorithm
Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1, Contract No. 290-2012-00009-I. Prepared by: Vanderbilt Evidence-based Practice Center, Nashville, TN
Suggested citation:
Likis FE, Sathe NA, Morgans AK, Hartmann KE, Young JL, Carlson-Bremer D, Schorn M, Surawicz T, Andrews J. Management of Postpartum Hemorrhage. Comparative Effectiveness Review No. 151. (Prepared by the Vanderbilt Evidence-based Practice Center under Contract No. 290-2012-00009-I.) AHRQ Publication No. 15-EHC013-EF. Rockville, MD: Agency for Healthcare Research and Quality; April 2015. www.effectivehealthcare.ahrq.gov/reports/final.cfm.
This report is based on research conducted by the Vanderbilt Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2012-00009-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.
AHRQ or U.S. Department of Health and Human Services endorsement of any derivative products that may be developed from this report, such as clinical practice guidelines, other quality enhancement tools, or reimbursement or coverage policies, may not be stated or implied.
This report may periodically be assessed for the currency of conclusions. If an assessment is done, the resulting surveillance report describing the methodology and findings will be found on the Effective Health Care Program Web site at www.effectivehealthcare.ahrq.gov. Search on the title of the report.
None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.
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.ahrq.gov
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