Vol 91, No 1 (2020)
Review paper
Published online: 2020-01-31

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Epidemiology, prevention and management of early postpartum hemorrhage — a systematic review

Stepan Feduniw1, Damian Warzecha2, Iwona Szymusik2, Miroslaw Wielgos2
Pubmed: 32039467
Ginekol Pol 2020;91(1):38-44.


Early Postpartum Hemorrhage (EPH) is one of the leading causes of postpartum mortality. It is defined as blood loss of at
least 500 mL after vaginal or 1000 mL following cesarean delivery within 24 hours postpartum. The following paper includes
literature review aimed to estimate the incidence and predictors of early postpartum hemorrhage (EPH). Available prevention
and treatment methods were also assessed. The inclusion criteria for the study were met by 52 studies.
The exact frequency of EPH in different populations varies from 1.2% to 12.5%. Maternal, pregnancy-associated, laborcorrelated
and sociodemographic risk factors seem to be important predictors of EPH. In these cases appropriate prophylaxis
should be considered. However, EPH may occur without previous risk factors. The main reason for EPH is uterine atony
which contributes to up to 80% of cases of postpartum hemorrhage (PPH). Other common reasons for PPH include genital
tract injuries, placenta accreta or coagulopathies. Interestingly, the majority of uterotonics seem to have a similar effect.
However, carbetocin seems to be the most effective in certain situations.
Appropriate diagnosis of EPH is the most important issue. The treatment should be causative. The first-line treatment should
include uterotonics. Surgical interventions, if required, should be performed without delay, although preoperative uterine
tamponade should be considered due to its high effectiveness.
Medical staff training in medical simulation centers is an important factor that improves the outcomes of EPH treatment.
It provides adaptation to hospital protocols, team work improvement, self-confidence building, more accurate blood loss
evaluation and reduced perception of stress. The implementation of systematic trainings provides better outcomes in the future.

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  1. Schlembach D, Helmer H, Henrich W, et al. Peripartum Haemorrhage, Diagnosis and Therapy. Guideline of the DGGG, OEGGG and SGGG (S2k Level, AWMF Registry No. 015/063, March 2016). Geburtshilfe und Frauenheilkunde. 2018; 78(04): 382–399.
  2. World Health Organization (WHO). SpringerReference. .
  3. Prevention and Management of Postpartum Haemorrhage: Green-top Guideline No. 52. BJOG. 2017; 124(5): e106–e149.
  4. Practice Bulletin No. 183. Obstetrics & Gynecology. 2017; 130(4): e168–e186.
  5. Diaz V, Abalos E, Carroli G. Methods for blood loss estimation after vaginal birth. Cochrane Database Syst Rev. 2018; 9: CD010980.
  6. Girault A, Deneux-Tharaux C, Sentilhes L, et al. Undiagnosed abnormal postpartum blood loss: Incidence and risk factors. PLoS One. 2018; 13(1): e0190845.
  7. Touhami O, Marzouk SB, Kehila M, et al. Efficacy and safety of pelvic packing after emergency peripartum hysterectomy (EPH) in postpartum hemorrhage (PPH) setting. Eur J Obstet Gynecol Reprod Biol. 2016; 202: 32–35.
  8. Bloch EM, Ingram C, Hull J, et al. South Africa Program of the NHLBI Recipient Epidemiology and Donor Evaluation Study-III (REDS-III). Risk factors for peripartum blood transfusion in South Africa: a case-control study. Transfusion. 2018; 58(9): 2149–2156.
  9. Dunkerton SE, Jeve YB, Walkinshaw N, et al. Predicting Postpartum Hemorrhage (PPH) during Cesarean Delivery Using the Leicester PPH Predict Tool: A Retrospective Cohort Study. Am J Perinatol. 2018; 35(2): 163–169.
  10. Nyfløt LT, Sandven I, Stray-Pedersen B, et al. Risk factors for severe postpartum hemorrhage: a case-control study. BMC Pregnancy Childbirth. 2017; 17(1): 17.
  11. Ford JB, Patterson JA, Seeho SKM, et al. Trends and outcomes of postpartum haemorrhage, 2003-2011. BMC Pregnancy Childbirth. 2015; 15: 334.
  12. Nyfløt LT, Stray-Pedersen B, Forsén L, et al. Duration of labor and the risk of severe postpartum hemorrhage: A case-control study. PLoS One. 2017; 12(4): e0175306.
  13. Horie S, Nomura K, Nakagawa J, et al. Factors Associated with Blood Loss after Delivery in 1,294 Mothers with Full-Term Singleton Baby. Nihon Eiseigaku Zasshi. 2016; 71(3): 208–215.
  14. Miller CM, Cohn S, Akdagli S, et al. Postpartum hemorrhage following vaginal delivery: risk factors and maternal outcomes. J Perinatol. 2017; 37(3): 243–248.
  15. World Health Organization (WHO). SpringerReference. .
  16. Sotillo L, Calle MD, Magdaleno F, et al. Efficacy of carbetocin for preventing postpartum bleeding after cesarean section in twin pregnancy. The Journal of Maternal-Fetal & Neonatal Medicine. 2018: 1–5.
  17. Maher MA, Sayyed TM, Elkhouly NI. Different routes and forms of uterotonics for treatment of retained placenta: a randomized clinical trial. J Matern Fetal Neonatal Med. 2017; 30(18): 2179–2184.
  18. Mohamed Maged A, Ragab AS, Elnassery N, et al. Carbetocin versus syntometrine for prevention of postpartum hemorrhage after cesarean section. J Matern Fetal Neonatal Med. 2017; 30(8): 962–966.
  19. Cecilia M, Vijayaselvi R, Bansal R, et al. Ten units intravenous oxytocin over 2-4 h is as effective as 30 units over 8-12 h in preventing postpartum hemorrhage after cesarean section: A randomized controlled trial. Indian J Pharmacol. 2018; 50(5): 279.
  20. Widmer M, Piaggio G, Nguyen T, et al. Heat-Stable Carbetocin Versus Oxytocin to Prevent Hemorrhage After Vaginal Birth. Obstetrical & Gynecological Survey. 2018; 73(11): 613–614.
  21. Chaudhuri P, Mandi S, Mazumdar A, et al. Rectally administrated misoprostol as an alternative to intravenous oxytocin infusion for preventing post-partum hemorrhage after cesarean delivery. J Obstet Gynaecol Res. 2014; 40(9): 2023–2030.
  22. Şentürk Ş, Kağıtçı M, Balık G, et al. The Effect of the Combined Use of Methylergonovine and Oxytocin during Caesarean Section in the Prevention of Post-partum Haemorrhage. Basic Clin Pharmacol Toxicol. 2016; 118(5): 338–343.
  23. Shakur H, Roberts I, Fawole B, et al. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. The Lancet. 2017; 389(10084): 2105–2116.
  24. Sentilhes L, Winer N, Azria E, et al. Tranexamic Acid for the Prevention of Blood Loss After Vaginal Delivery. Obstetrical & Gynecological Survey. 2019; 74(1): 10–11.
  25. Aderoba AK, Olagbuji BN, Akintan AL, et al. Condom-catheter tamponade for the treatment of postpartum haemorrhage and factors associated with success: a prospective observational study. BJOG. 2017; 124(11): 1764–1771.
  26. Practice Bulletin No. 183. Obstetrics & Gynecology. 2017; 130(4): e168–e186.
  27. Marshall AL, Durani U, Bartley A, et al. The impact of postpartum hemorrhage on hospital length of stay and inpatient mortality: a National Inpatient Sample-based analysis. Am J Obstet Gynecol. 2017; 217(3): 344.e1–344.e6.
  28. Lier H, von Heymann C, Korte W, et al. Peripartum Haemorrhage: Haemostatic Aspects of the New German PPH Guideline. Transfus Med Hemother. 2018; 45(2): 127–135.
  29. Burns E, Hunter L, Rodd Z, et al. Developing and evaluating an online learning tool to improve midwives' accuracy of visual estimation of blood loss during waterbirth: An experimental study. Midwifery. 2019; 68: 65–73.
  30. Marshall NE, Vanderhoeven J, Eden KB, et al. Impact of simulation and team training on postpartum hemorrhage management in non-academic centers. J Matern Fetal Neonatal Med. 2015; 28(5): 495–499.
  31. Letchworth PM, Duffy SP, Phillips D. Improving non-technical skills (teamwork) in post-partum haemorrhage: A grouped randomised trial. Eur J Obstet Gynecol Reprod Biol. 2017; 217: 154–160.
  32. van de Ven J, Fransen AF, Schuit E, et al. Does the effect of one-day simulation team training in obstetric emergencies decline within one year? A post-hoc analysis of a multicentre cluster randomised controlled trial. Eur J Obstet Gynecol Reprod Biol. 2017; 216: 79–84.
  33. Charles D, Anger H, Dabash R, et al. Intramuscular injection, intravenous infusion, and intravenous bolus of oxytocin in the third stage of labor for prevention of postpartum hemorrhage: a three-arm randomized control trial. BMC Pregnancy Childbirth. 2019; 19(1): 38.
  34. Sørensen JL, van der Vleuten C, Rosthøj S, et al. Simulation-based multiprofessional obstetric anaesthesia training conducted in situ versus off-site leads to similar individual and team outcomes: a randomised educational trial. BMJ Open. 2015; 5(10): e008344.