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Effective Health Care Program

Management of Postpartum Hemorrhage

Systematic Review

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Structured 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.