Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

Our topic of nomination is Postpartum Hemorrhage. The following is a list of clinical questions practitioners consider when managing such cases:

• What should be considered in the initial evaluation of a patient with excessive bleeding in the immediate postpartum period?
• What is the appropriate medical management approach for excessive postpartum bleeding?
• When is packing or tamponade of the uterine cavity advisable?
• When are surgical techniques used to control uterine bleeding?
• What are the clinical considerations for suspected placenta accreta?
• Under what circumstances is arterial embolization indicated?
• When is blood transfusion recommended? Is there a role for autologous transfusions or directed donor programs?
• What is the management approach for hemorrhage due to a ruptured uterus?
• What is the management approach for an inverted uterus?
• What is the management approach for secondary postpartum hemorrhage?
• What is the best approach to managing excessive blood loss in the postpartum period once the patient's condition is stable?

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

-Comparing different misoprostol dosing recommendations -Comparing effectiveness of different oxytocin agents -Methods on estimating blood loss -Alternative blood products

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

Postpartum women

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

We are interested in balancing the use of minimally invasive conservative management techniques with the need to control the bleeding and achieve hemostasis.

Describe any health-related risks, side effects, or harms that you are concerned about.

Treatment and management strategies are aimed at preserving future fertility as well as preventing uterine atony and associated bleeding. Sequelae include adult respiratory distress syndrome, coagulopathy, shock, loss of fertility, and pituitary necrosis (Sheehan syndrome).

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

yes

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

• Pregnancy, including preterm birth

AHRQ Priority Populations

• Women

Federal Health Care Program

None

Importance

Describe why this topic is important.

Severe bleeding is the single most significant cause of maternal death worldwide. More than half of all maternal deaths occur within 24 hours of delivery, most commonly from excessive bleeding. It is estimated that, worldwide, 140,000 women die of postpartum hemorrhage each year--one every 4 minutes. In addition to death, serious morbidity may follow postpartum hemorrhage. As management of postpartum hemorrhage may vary greatly among patients, it is important to provide practitioners with information designed to aid making decisions about appropriate care.

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

In a rudimentary literature search of new data, we found about 250 relevant RCTs, meta-analysis, clinical trials, and systematic reviews published since the publication of ACOG Practice Bulletin #76 (2006). In nominating this topic, we hope that the EPC systematic review will assist us in developing a comprehensive and updated guideline for the management of postpartum hemorrhage.

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

yes

If yes, please explain:

Treatment of postpartum hemorrhage varies widely among practitioners, and among medical specialties. A uniform approach supported by evidence will help to improve care for women by moving practitioners to follow similar well-supported protocols.

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

Clinicians will be more equipped to make appropriate management decisions in postpartum hemorrhage based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.

Describe the timeframe in which an answer to your question is needed.

This topic will be reviewed by ACOG's Committee on Obstetrics Practice in October 2013. Having a systematic review to report to the committee at this time would be extremely beneficial to the decisions related to updating our current guideline.

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

Postpartum hemorrhage is not unique to any particular population, but the resources available for treatment vary widely. Identifying the most effective and least resource intensive management approaches would be particularly helpful in low-resource settings.

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

Clinicians will be more equipped to make appropriate management decisions in postpartum hemorrhage based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.

Are you making a suggestion as an individual or on behalf of an organization?

Organization

Please tell us how you heard about the Effective Health Care Program

Stephanie Chang, MD MPH (Agency for Healthcare Research and Quality)