Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Restate the ACOG definition of postpartum hemorrhage
2. List the drugs that have been shown to be effective in managing post partum hemorrhage

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Sema4, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Dec 31 2020, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Designated for 0.1 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.

Read Disclaimer & Fine Print

ACOG defines PPH as cumulative blood loss ≥ 1,000 mL or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after the birth process (including intrapartum) regardless of route of delivery. Unfortunately, postpartum hemorrhage (PPH) is still a leading cause of maternal mortality worldwide.  Following this summary, you can find excellent professional resources at the California Maternal Quality Care Collaborative (CMQCC) and ACOG District II Safe Motherhood Initiative sites. 

CLINICAL ACTIONS:

In the setting of PPH, consider the 4 ‘T’s

• Tone (atony)
• Trauma (laceration)
• Tissue (retained products)
• Thrombin (coagulopathy)

Uterine atony is the single most common cause of PPH (70-80%)

• Empty bladder, perform bimanual pelvic exam, remove clots and initiate uterine massage
• There is lack of evidence to determine which specific uterotonics are superior (good and consistent scientific evidence – ACOG level A)
  • Choice at provider’s discretion
• If uterine atony is identified,  the following drugs have been shown to be effective:

NOTE: Contraindications include hypersensitivity to the specific medication

More on Tranexamic Acid (TXA)

ACOG Update (2017)

• In the WOMAN trial (see Related OBG Topics below) women with PPH received
  • 1 g in 10 mL (100 mg/mL) of tranexamic acid intravenously at a rate of 1 mL per min (i.e., over 10 min)
  • If bleeding continued after 30 min or stopped and restarted within 24 h of the first dose, a second dose of 1 g of tranexamic acid could be given
• Tranexamic acid, administered within 3 hours of birth, has been shown to significantly reduce maternal death due to PPH by approximately 30%
• Based on improved outcomes and lack of adverse events including thromboembolism, ACOG has updated the practice bulletin to include the following

Although the generalizability of the WOMAN trial and the degree of effect in the United States is uncertain, given the mortality reduction findings, tranexamic acid should be considered in the setting of obstetric hemorrhage when initial medical therapy fails. (Level B evidence)

World Health Organization Update (2017)

Based on evidence review, WHO also supports the use of tranexamic acid with postpartum hemorrhage

Early use of intravenous tranexamic acid (within 3 hours of birth) in addition to standard care is recommended for women with clinically diagnosed postpartum haemorrhage following vaginal birth or caesarean section (Strong recommendation, moderate quality of evidence)

Administration of TXA should be considered as part of the standard PPH treatment package and be administered as soon as possible after onset of bleeding and within 3 hours of birth

The reference point for the start of the 3-hour window for starting TXA administration is time of birth

If time of birth is unknown, the best estimate of time of birth should be used as the reference point

TXA should be used in all cases of PPH, regardless of whether the bleeding is due to genital tract trauma or other causes

SYNOPSIS:

The key to managing PPH is identifying the severity of the situation early and quantifying estimated blood loss (EBL).  A 2nd large bore (16 gauge or larger) should be placed and Ringers Lactate used to replace blood loss at 2:1 while, at the same time that the team is notified, medications are brought to the patient and massive transfusion protocol is initiated.  Initiate fundal massage and place a Foley catheter.

KEY POINTS:

• ABCs
  • Airway: Assess and stabilize
  • Breathing: Supplemental oxygen, 5-7 L/min by tight face mask
  • Circulation: do NOT wait for change in vitals
    • Compromised blood volume: pallor, delayed capillary refill and decreased urinary output
    • Late signs: decreased BP and tachycardia
• Consider intrauterine balloon tamponade or compression sutures for refractory atony
• Surgical Interventions may be a life-saving measure and should not be delayed while waiting to correct coagulopathy
• Quantitative measurement of blood loss is more acurate than visual estimation (see ‘Learn More – Primary Sources’ below) and required 2 key elements
  • Direct measurement of blood loss
  • Protocols for collecting and reporting a cumulative record of
  • Blood loss following delivery

Learn More – Primary Sources:

ACOG District II Safe Motherhood Initiative – Obstetric Hemorrhage

NY State DOH Health Advisory:  Prevention of Maternal Deaths Through Improved Management of Hemorrhage

AWHONN video: Quantification of Blood Loss

ACOG Committee Opinion 794: Quantitative Blood Loss in Obstetric Hemorrhage

ACOG Practice Bulletin 183: Postpartum Hemorrhage

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

California Maternal Quality Care Collaborative (CMQCC): OB Hemorrhage ToolkitV2.0

WHO recommendation on tranexamic acid for the treatment of postpartum haemorrhage

Updated WHO Recommendation on Tranexamic Acid for the Treatment of Postpartum Haemorrhage Highlights and Key Messages from the World Health Organization’s 2017 Global Recommendation

Related ObG Topics:

Results From the Landmark Trial on Tranexamic Acid for Postpartum Hemorrhage

Does ART Increase Risk of Postpartum Hemorrhage?

Placenta Previa – Nomenclature, Diagnosis and Clinical Management

Postpartum Hemorrhage Prophylaxis: The World Health Organization Recommendations