Definition, management strategies, and risk assessment of obstetric hemorrhage: a narrative review

Introduction

Background

The definition of postpartum hemorrhage (PPH) varies, with differences in blood loss thresholds, timing (primary vs. secondary), measurement methods, and mode of delivery, highlighting the need for standardized definitions in research and practice. Excessive blood loss following childbirth, defined as 500 milliliters (mL) for vaginal delivery or 1,000 mL for cesarean delivery (CD), is known as PPH (1). PPH can be primary, occurring within the first 24 hours after childbirth, or secondary, occurring from 24 hours up to 12 weeks postpartum (2,3).

PPH is a serious maternal health issue, responsible for over 27% of maternal fatalities globally (4). It is a primary contributor to maternal mortality especially in low- and middle-income nations, where maternal mortality rates could exceed 400 deaths per 100,000 live births due to insufficient healthcare access and emergency obstetric services (5). PPH affects 1% to 5% of all births worldwide, with 1% to 3% of those cases being considered severe (6). Global data from the World Health Organization (WHO) reveal that hemorrhage accounts for over 70,000 maternal deaths annually, with a staggering 88.4% of these fatalities occurring in low- and middle-income countries, particularly across regions in Asia, Africa, Latin America, and the Caribbean. Interestingly, while the burden is disproportionately high in these settings, even high-income countries report PPH contributes up to 13% of maternal mortality cases, highlighting that this life-threatening condition remains a significant challenge worldwide (7). A history of preeclampsia, multiparity, prolonged labor, obesity, and anemia are common risk factors. The increasing prevalence of PPH, especially in well-resourced settings, emphasizes the necessity for efficient risk evaluation, prompt diagnosis, and appropriate treatments to enhance maternal health outcomes and reduce the effects of this potentially life-threatening condition (3).

Rationale and knowledge gap

PPH is a significant global health issue, contributing to maternal morbidity and mortality. PPH affects 1% to 5% of all births, with 1% to 3% of cases considered severe, and continues to be a leading cause of maternal death worldwide (8). Despite advancements, PPH risk assessment tools remain under-validated, particularly across diverse populations, which hampers the design of effective interventions. The definition of PPH remains unclear, with discrepancies in blood loss thresholds and timing, complicating early diagnosis and management (9). Additionally, there has been limited exploration of emerging technologies like telemedicine and artificial intelligence (AI), which may have considerable potential, especially in resource-constrained environments (3). This gap highlights the urgent need for improved strategies in the identification, diagnosis, and treatment of PPH.

Objective

This review aims to give an overview of the current status of the PPH definition, epidemiology, and clinical management strategies, with a focus on improving risk assessment and clinical outcomes. Educating healthcare practitioners, improving clinical standards, and applying evidence-based procedures are critical to properly managing this condition. Furthermore, increasing community knowledge of the potential risks associated with PPH and the significance of immediate medical care can help lessen its occurrence and severity. We present this article in accordance with the Narrative Review reporting checklist (available at https://aob.amegroups.com/article/view/10.21037/aob-24-33/rc).

Methods

Peer-reviewed literature containing the keywords “PPH, diagnosis, limits, management, fibrinogen concentrate, tranexamic acid, artificial intelligence (AI), and blood loss”, published in English in PubMed from 2012 to September 2024 has been reviewed (Table 1).

Findings

Epidemiology and diagnosis of PPH

Definition of PPH

The definition of PPH is primarily based on the volume of blood loss that occurs after childbirth. The definition of PPH should include both hemorrhage and the clinical signs and symptoms of the cardiovascular system following delivery, which assists healthcare providers in achieving prompt and effective diagnosis. PPH is commonly defined by combining the total volume of blood loss and the mode of delivery. The WHO and the Royal College of Obstetricians and Gynecologists define PPH as the loss of a minimum of 500 mL of blood from the genital tract within 24 hours following birth, irrespective of whether the delivery was vaginal or via CD (10,11). Conversely, the definitions provided by the International Federation of Gynecology and Obstetrics, along with those from the Chinese Ministry of Health and Queensland Health, categorize PPH as a loss of at least 500 mL during a vaginal birth or 1,000 mL in a CD (12,13). It can also be characterized by a total blood loss of 1,000 mL or more, or any blood loss that results in hypotension within 24 hours shortly after delivery, regardless of the mode of delivery, according to the American College of Obstetrics and Gynecology (1).

Interestingly, little research has been focused on if these thresholds of blood loss apply to all body types or starting risk factors. For example, a person with a body mass index of 20 versus 50 kg/m² will tolerate 1,000 mL of blood loss differently given their baseline circulating blood volume differ significantly (14). Furthermore, a person with severe anemia and a hemoglobin of 7 g/dL versus a hemoglobin of 11 g/dL will likely become coagulopathic at lower relative volumes of blood loss (15). Additional consideration should be given for revisiting the definition of PPH by blood loss volume criteria alone (16,17).

Accurate evaluation of blood loss is critical for the well-timed identification of PPH, thereby improving maternal outcomes. Visual estimation is the main method for evaluating blood loss in numerous delivery settings, especially in low- and middle-income countries, but its accuracy regularly falls short and many cases go undiagnosed (18). Research demonstrates that quantitative techniques, which include weighing blood-soaked and calibrated container materials, have greater accuracy estimates of blood loss than visual estimation (19). Recent studies have discussed using ultrasound technology for real-time quantity estimation during PPH events, indicating its capability as a non-invasive and effective adjunct to traditional techniques, even though extra validation is required (20). Perhaps for certain patients with obesity where fundal checks are not as reliable to identify recurrent atony, this technology may be helpful. Emerging technologies, including wearable devices and mobile applications, enable real-time monitoring and assessment of blood loss during and after childbirth (21). Accurate and ongoing updated evaluation of blood loss during a PPH are critical elements to early recognition and management by the clinical team.

Epidemiology of maternal hemorrhage: incidence and distribution

Maternal mortality rates vary significantly by geographic location, reflecting disparities in healthcare access, quality, and socio-economic status. Maternal mortality represents the total count of maternal deaths occurring during pregnancy, within the first 42 days postpartum, or following the termination of a pregnancy (22).

Maternal death by cause, world

Policies and health-care programming decisions must be based on a thorough understanding of the factors that contribute to maternal fatalities. The United Nations Maternal Mortality Estimation Inter-Agency Group—comprising WHO, the United Nations Children’s Fund, the United Nations Population Fund, the World Bank Group and the United Nations Department of Economic and Social Affairs, Population Division has partnered with external technical experts to provide updated estimates of the primary causes of maternal mortality worldwide for the period from 2000 to 2020, as presented in Table 2 (23). PPH is a significant factor in maternal mortality worldwide, accounting for around 27% of cases, according to WHO reports (7). In the United States, hemorrhage is responsible for 14% of all maternal deaths, according to data from the Centers for Disease Control and Prevention (7). PPH is the most common type, often resulting from uterine atony, retained placenta, or trauma during delivery (24).

Maternal death by region, world

The maternal mortality rates vary significantly across different regions globally. This disparity indicates that certain regions enjoy more effective access to healthcare, enhanced quality of life, and more efficient health systems (15). Figure 1 shows the number of pregnancy-related deaths around the world from 2005 to 2020. The majority of pregnancy-related deaths each year occur in Africa and Asia. In 2020, these two areas were responsible for about 87% of all maternal fatalities. Approximately 70% of these fatalities occurred in Sub-Saharan Africa.

Figure 1 Maternal death by region, world (2005 to 2020). UN MMEIG, United Nations Maternal Mortality Estimation Inter-Agency Group.

Genetic factors contributing to PPH

Along with the medical risk factors we have discussed, there could also be a genetic component contributing to the risk of PPH. A study from 2014, looking at almost 500,000 births from Sweden, found that a mother’s genes could explain up to 18% of why some women have PPH (25). Research on the genetic factors that contribute to PPH is limited. Some genetic conditions, like von Willebrand disease or other hereditary bleeding disorders, are often under diagnosed and there are likely other coagulopathy disorders for pregnant women that are not well categorized (26).

Risk assessment tools and limitations in PPH

Tools for assessing the risk of PPH are important for identifying women who are more likely to experience heavy bleeding after childbirth. These tools help healthcare providers quickly decide on the best treatments and management plans to prevent severe bleeding, which can ultimately improve the health outcomes (27). Risk assessment also helps in organizing medical resources and staff, making sure that women who need more attention and care get it.

Category-based PPH risk assessment tools

The risk assessment tools for PPH are categorized by clinical factors into low, medium, and high-risk groups. Examples of such groups include the Association of Women’s Health, Obstetric and Neonatal Nurses, the New York Safety Bundle for Obstetric Hemorrhage, and the California Maternal Quality Care Collaborative (7). These tools assess patient history (e.g., previous PPH, CD), pregnancy-specific factors (e.g., multiple gestations, anemia, preeclampsia), and labor-related circumstances (e.g., prolonged labor, uterine overdistention) as shown in Table 3. A retrospective multicenter study demonstrated that the Association of Women’s Health, Obstetric and Neonatal Nurses hemorrhage risk-prediction tool effectively identifies patients at elevated risk for obstetric hemorrhage and can function as a screening tool for individuals at risk of hemorrhage-related morbidity (27). However, the limitation of this tool lies in its low positive predictive value of 32%, meaning that 68% of individuals classified as high-risk did not experience the anticipated complications. This high false positive rate suggests that while the tool effectively identifies high-risk individuals, its accuracy in predicting actual morbidity remains limited (27).

Despite their frequent use, these tools have specific limitations. The classifications presented are broad, and this may overlook specific variations among individuals or elements that arise throughout the labor process (28). While these tools aid healthcare providers in preparation and management, they require ongoing patient monitoring and personalized attention (28).

Machine learning-based prediction of PPH

AI and machine learning are advancing rapidly in the domain of PPH prediction and prognosis. These technologies may enhance the early detection of PPH cases, optimize obstetric outcomes, and improve clinical decision-making among providers. AI may assist in identifying women at increased risk for PPH by analyzing extensive datasets encompassing population demographics, health records, and clinical parameters (29). In addition, it may evaluate factors like the medical history, any preexisting concerns about the pregnancy, and the patient’s vital signs to establish the order of intervention and monitoring. Challenges with the utilization of machine learning techniques have been inability to validate on an external data set (30). Future trials will likely incorporate AI and machine learning tools into clinical practice, assessing their capability to reduce maternal morbidity and mortality associated with PPH (20).

Modified Early Warning Score (MEWS)

The MEWS assesses the patient’s health status and detects clinical deterioration. MEWS gives a numerical score predominantly based on physiological parameters such as heart rate, systolic blood pressure, respiratory rate, temperature, and level of consciousness (31). A higher score signifies that the individual is deteriorating and requires intervention. Concerning PPH, it inadequately detects the first stages of PPH, as certain vital signs, such as blood pressure and heart rate, may remain stable despite considerable blood loss. Furthermore, initial indicators of hemorrhage may be masked by physiological alterations that occur during pregnancy, including elevated heart rate and blood volume. This may result in a delay in the identification of the hemorrhage (32). In addition, important obstetric indicators like uterine atony and blood loss volume are not considered (33,34). Providers may delay necessary interventions or give false assurances because of these limitations. Hence, MEWS is essential in a high-volume healthcare system or settings with limited personnel, along with clinical judgment and other evaluation methods.

Laboratory tests for PPH in high- and low-resource settings

In high-resource settings, various established techniques are available for diagnosing PPH, facilitating expedited treatments and enhanced outcomes. The complete blood count and coagulation profile provide critical insights into hemoglobin levels and clotting function, encompassing prothrombin time, activated partial thromboplastin time, and fibrinogen levels (35). Collectively, these tests yield essential information to facilitate prompt and efficient handling of PPH (35). Conversely, changes in peripartum hemoglobin levels can indicate different forms of blood loss, including hemodilution with intravenous (IV) fluids, internal formation of hematomas, and hemolysis (36). Ultrasound may be helpful for diagnosing and managing PPH, often in the setting of retained placenta (37). Healthcare practitioners can respond immediately to blood loss with the help of rapid tests, such as point-of-care hemoglobin devices, which allow them to assess hemoglobin levels (38). However, these tests can over or underestimate blood loss depending on rapid volume shifts, so combining lab results with vital signs is key for effective PPH resuscitation.

PPH is characterized by significant blood loss after vaginal delivery (39), however, internal bleeding, such as that resulting from vaginal or broad ligament hematomas, may not be identified as abnormal if not visually estimated or measured by gravimetric methods (36). In low-resource settings with restricted access to advanced medical equipment, the diagnosis and management of PPH present considerable challenges. Basic, low-cost instruments, such as bedpans, calibrated collection bags, and visual assessments, are employed to estimate blood loss (18). Additionally, clinical evaluations such as vital signs and physical examinations assist in the detection of PPH (35). However, the lack of qualified professionals and medical resources frequently leads to treatment delays, undermining the quality of care, escalating complications, and heightening morbidity and mortality rates. Community health professionals are essential in providing education to women and families about identifying signs of bleeding and understanding when it is necessary to seek medical assistance. It is crucial to address resource deficiencies and bolster community education to enhance patient care, facilitate timely interventions, and avert negative outcomes (40,41).

In recent years, advanced hemostatic testing technologies, including thromboelastography (TEG), The Quantra^® System (HemoSonics, Charlottesville, VA, USA), and rotational thromboelastometry (ROTEM), have become increasingly utilized for the rapid diagnosis and management of coagulopathy, especially in critical situations such as PPH (42). These point-of-care viscoelastic testing (POCT) offer a thorough, real-time evaluation of the complete coagulation process, encompassing clot formation, strength, stability, and fibrinolysis (42,43). The TEG system, commonly utilized in clinical practice, provides detailed insights into clot initiation, development, and dissolution, assisting healthcare providers in customizing treatment according to the underlying cause of hemorrhage (44). The Quantra^® System utilizes Sonic Estimation of Elasticity via Resonance (SEER) sonorheometry (HemoSonics), a patented ultrasound technology that measures clot stiffness over time through ultrasound-induced resonance (45). ROTEM, a form of POCT, offers measures analogous to TEG but employs a distinct technological methodology (46).

A systematic review and meta-analysis combining data from four cohort studies and one randomized clinical trial showed that POCT for transfusion management in parturient with PPH led to significantly improved outcomes compared to empirical transfusion protocols (47). In particular, transfusions guided by POCT led to a decrease in the likelihood of emergency hysterectomy, transfusion-associated circulatory overload, and the requirement for blood products such as fresh frozen plasma and platelets (47). Another systematic review that included eight observational studies and nine randomized clinical trials in patients undergoing heart surgery found that POCT-based coagulation management decreased re-exploration rates, decreased exposure to allogeneic blood products, and decreased the incidence of thromboembolic events and postoperative acute kidney injury (48). However, the review indicated no notable differences in mortality rates, or the duration of intensive care unit (ICU) stay and pointed to low-quality evidence. Compared to robust data in cardiac surgery data evaluating POCT devices in transfusion management, evidence in obstetrics is lagging (47,48).

Pharmacology, devices, and management of PPH

Tranexamic acid (TXA) latest and future trials

TXA is a medication approved by the U.S. Food and Drug Administration for menorrhagia or the short-term prevention of hemophilia patients undergoing procedures (49). In obstetrics, many recent trials have studied the use of TXA at the time of delivery as summarized in Table 4. WHO currently recommends the use of IV TXA within 3 h of birth for women with clinically diagnosed PPH after vaginal birth or CD. Also, the potential role of TXA in preventing PPH with ongoing studies is currently being explored (NCT04304625, NCT05562609). This antifibrinolytic agent works by inhibiting blood clot breakdown and has demonstrated a reduction in mortality related to PPH when given early. Retrospective US national data shows a significant increase in TXA use at delivery, with higher rates of PPH history or estimated blood loss ≥1,000 mL among recipients (55).

The large clinical trial data (summarized in Table 4) began with the WOMAN trial, which showed that TXA significantly reduces mortality associated with PPH and should be administered promptly following the diagnosis of PPH (50). The WOMAN-2 trial enrolled patients with moderate to severe anemia, administering TXA within 15 minutes after umbilical cord clamping. While the reduction in the risk of clinically diagnosed PPH was not statistically significant, it is noteworthy that 35% of participants received the full treatment dosage following a diagnosis of PPH (51). The TRAAP trial assessed the effects of TXA on PPH following vaginal delivery. Although TXA did not significantly decrease PPH rates, it did reduce the incidence of provider-assessed PPH necessitating further uterotonic intervention. These results indicate a rate of PPH that was not significantly lower than the rate with a placebo (51). The TRAAP2 trial, which focused on women undergoing CD and administration of TXA at the umbilical cord clamp, showed that TXA significantly reduced the occurrence of blood loss greater than 1,000 mL or the need for transfusion within 48 hours postpartum. PPH occurred in 556 of 2,086 women (26.7%) in the TXA group and in 653 of 2,067 (31.6%) in the placebo group. TXA treatment resulted in a 5% reduction in these outcomes relative to placebo, significantly lowering the incidence of excessive blood loss and the necessity for transfusions among deliveries (56).

The Maternal-Fetal Medicine Unit Network clinical trial assessed the prophylactic administration of TXA during CD and found no significant decrease in maternal mortality or blood transfusion risk relative to placebo. Importantly, in their limitations, they acknowledged that given administration was at umbilical cord clamp, it is unknown the benefits if TXA is given before delivery (57).

A recent meta-analysis of the large clinical trials mentioned above published in The Lancet demonstrated a significant reduction in life-threatening bleeding in the TXA group. Specifically, 178 (0.65%) of 27,300 women in the TXA group experienced life-threatening bleeding, compared to 230 (0.85%) of 27,093 women in the placebo group. Importantly, there was no evidence that the odds ratio varies with underlying risk of life-threatening bleeding, presence or absence of moderate or severe anemia or type of birth. In addition, no significant differences were observed in thromboembolic events between the groups (58).

Fibrinogen concentrate (FC) and emerging hemostatic agents in PPH management

FC is increasingly recognized as a critical intervention for PPH, as fibrinogen is the first coagulation factor to decrease during significant bleeding and is a unique marker associated with severe PPH (59). Compared to fresh frozen plasma, which contains clotting factors, and cryoprecipitate, FC provides a more concentrated and targeted source of fibrinogen. The growing support for its use in clinical settings reflects its potential benefits. However, further evidence-based studies are essential to confirm its clinical effectiveness in managing PPH (52). In addition, cost effectiveness studies in obstetrics for its use versus cryoprecipitate are lacking (53).

Wikkelsø and colleagues performed a large double-blind, randomized trial to compare fibrinogen infusion with placebo in patients undergoing significant bleeding. The research indicated that administering FC at a fixed dose, without evaluating plasma fibrinogen levels, showed no advantage when blood loss reached 1,500 mL. Furthermore, 46 patients, accounting for 15% of the bleeding cohort, were excluded from randomization due to severe bleeding and the lack of informed consent. This group may have derived the greatest benefit from the intervention, underscoring the difficulty of aligning study inclusion criteria to identify individuals who would gain the most from treatment. This study highlights the necessity for enhanced selection criteria and more precise methodologies for the administration of FC, including the integration of real-time fibrinogen measurements to inform treatment decisions (52).

Collins et al. (54) did not demonstrate a significant improvement in outcomes for women with fibrinogen levels greater than 2 g/L who were administered FC. However, in women with fibrinogen levels less than 2 g/L, the median blood loss was significantly lower in the FC group compared to the placebo group. This suggests that FC may be particularly beneficial for women with lower fibrinogen levels, though the lack of outcome improvement in those with higher levels warrants further investigation.

Devices/materials for managing PPH in high and low-resource settings

Uterine tamponade devices such as the Bakri/Ebb balloon (Argon Medical Devices, Frisco, TX, USA) have been used in high-resource settings and alternative strategies in resource-limited settings have also been employed (60). The Jada system (Jersey City, NJ, USA) is a relatively newer intrauterine device that employs low-level vacuum pressure to facilitate natural uterine contractions, to manage abnormal postpartum uterine bleeding or PPH following childbirth (61). To compare the effectiveness of the Bakri intrauterine balloon with the vacuum-induced Jada system, a recent multicenter retrospective study was published (61). The results showed that transfusion rates and blood loss after device placement were similar, and that earlier placement of the device reduced both device failure and the need for transfusion. The PEARLE study was a multicenter, prospective, single-arm trial that evaluated the safety and efficacy of the Jada system. Twelve U.S. hospitals conducted the study, involving 99 unique investigators and 106 patients, with a 6-week follow-up period. The primary effectiveness endpoint was reached in 94% of cases, underscoring the device’s capability to address PPH (62). Having a lower-cost version of such an effective device would greatly add to the tools/resources for hysterectomy-sparing techniques in resource-limited settings. A multidisciplinary team of investigators in two units in Ghana will enroll 424 women to evaluate the effectiveness of the Jada system, safety and cost effectiveness of it compared to standard care in treating PPH (NCT05382403). Condom catheters have also been explored as a low-cost alternative to more traditional uterine tamponade devices. A study by Anger et al. (63) demonstrated that introducing condom-catheter uterine balloon tamponade in secondary-level hospitals in Uganda, Egypt, and Senegal effectively managed PPH, offering a cost-effective solution in low-resource settings. Of note, the WHO recommends the use of uterine tamponade devices only in contexts where additional supportive interventions are available if needed (64).

Compression sutures, such as the B-Lynch technique, are commonly employed as a conservative surgical approach to manage uterine atony. This method is widely recommended in clinical practice for its effectiveness in controlling PPH due to uterine atony (65).

The sponge tamponade, particularly the XStat Mini Sponge Dressing (MSD) (RevMedX, Wilsonville, OR, USA), represents an innovative method for addressing PPH. This device employs advanced medical sponges that are highly compressed and expand upon contact with blood, effectively applying pressure to swiftly manage bleeding. An animal study was performed to test using a uterine model for comparison of MSD with traditional methods like uterine packing and balloon tamponade with pressure sensor for measurement fundal pressure, reduction in fluid loss, time to deploy, and time to remove (66). The MSD’s highest fundal pressure was (113 mmHg) followed by the MSD bag device (85.8 mmHg), gauze packing (15.5 mmHg), and the uterine balloon (8.2 mmHg). The MSD bag test group achieved the largest fluid flow reduction of −74% followed by gauze packing −55%, MSD −35%, and uterine balloon −19%. The application time of the test materials ranged from seconds (11 s for MSD and 12 s for MSD bag) to several minutes (3 min) for the uterine balloon. The removal time varied from 10 s for MSD bag and gauze and 4 min for MSD.

Preliminary clinical trials have demonstrated encouraging outcomes, as the device successfully halts bleeding in a matter of minutes. The applicator was enlarged to facilitate placement as well as using larger MSD for filling a postpartum uterus, also MSD is secured within a strong porous pouch to facilitate manual vaginal removal (67). Notably, there were no reported adverse events, and all patients maintained an afebrile state without the need for further surgical intervention (68). Additional larger clinical trials assessing efficacy and safety in larger numbers are needed before more widespread utilization.

Blood management in PPH

Optimizing with IV iron pre-delivery

Enhancing iron levels during pregnancy is crucial for avoiding iron deficiency anemia, a prevalent issue that may result in negative consequences for both the mother and the fetus. IV iron is frequently utilized when oral iron supplements prove inadequate response or are not well tolerated because of gastrointestinal side effects. IV iron effectively replenishes iron stores and enhances hemoglobin levels, providing a prompt solution for women experiencing considerable iron deficiency. Some studies indicate that IV iron administration during pregnancy can improve iron absorption and elevate hemoglobin levels more effectively than oral supplements, especially in instances of severe anemia or when adherence to oral supplementation is a concern (69,70).

Anemia affects approximately one billion women of reproductive age, with around 20 million experiencing severe forms of the condition (71). The prevalence of anemia has been increasing in many regions worldwide (72). Women experiencing anemia have an increased chance of PPH, making it crucial to initiate preventive measures against anemia as early as possible, preferably before conception. The WOMAN 3 trial, set to commence in 2025, aims to explore the impact of administering TXA during menstruation alongside iron and folic acid as a treatment approach for anemia (51).

Transfusion algorithms

Managing obstetric hemorrhage, particularly PPH, often involves a structured transfusion algorithm to ensure timely and effective treatment. These steps are part of a comprehensive approach to managing PPH, aiming to stabilize the patient, control bleeding, and correct coagulopathies. Viscoelastic testing can often help with conventional laboratory testing to guide optimal management. Transfusion algorithms for PPH differ from those for non-pregnancy-related hemorrhage due to unique physiological and clinical considerations. At PPH, rapid activation of packed red blood cells as first line products often with others such as fresh frozen plasma, platelets or cryoprecipitate/FC to maintain hemostasis is crucial due to the potential for rapid deterioration (67). There is limited data to support optimal transfusion specific algorithms for PPH.

Cell salvage in obstetrics

Cell salvage is an innovative technique increasingly used during pregnancy where blood loss is collected using a cell salvage machine that separates just red blood cells and then is washed and filtered to remove any contamination, and the cleaned red blood cells are reinfused into the patient through an IV line (66). Use of cell salvage during CD reduces allogenic blood transfusion without increasing risk of complications, including no cases of amniotic fluid embolism (73).

Strengths and limitations

This review synthesizes current pharmacological and non-pharmacological strategies for PPH management, incorporating both established and emerging interventions. It highlights advancements such as FC and AI-based risk assessment while addressing limitations in current diagnostic tools.

However, the review is limited by its inclusion of English-language studies, potential heterogeneity in study designs, and variations in healthcare settings. The lack of large-scale clinical validation for some emerging therapies further restricts definitive conclusions. Future research should focus on multicenter trials to enhance generalizability.

Conclusions

This narrative review addresses the most recent advances and challenges in the management of PPH, focusing on pharmaceutical therapies, medical devices, and blood management strategies. Risk assessment tools at this time are helpful somewhat and likely will improve with additional technology and prospective validation with refinement. Although TXA has demonstrated significant advantages in reducing PPH mortality, especially when administered promptly, its application in preventive contexts and among particular patient groups requires further exploration (3). Similarly, the application of FC in cases of severe PPH still needs further evaluation. Devices like the Bakri balloon and recent advancements such as the Jada system or XStat MSD can be potential non-pharmacologic adjuncts to the management of PPH. More robust data on their role in lower resource settings are needed given a majority of deaths due to bleeding take place in low resource settings. Blood management strategies like IV iron and cell salvage present considerable benefits, especially in situations involving anemia, underlying coagulopathy or considerable blood loss. Pharmacological advancements, AI updated algorithms, cutting-edge medical devices, and tailored blood management strategies will undoubtedly shape the future of PPH management, but their implementation requires a keen awareness of their limitations and contextual factors.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://aob.amegroups.com/article/view/10.21037/aob-24-33/rc

Peer Review File: Available at https://aob.amegroups.com/article/view/10.21037/aob-24-33/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aob.amegroups.com/article/view/10.21037/aob-24-33/coif). H.K.A. reports receiving the R01HD110109 grant, and serving as consultant of Coagulant Therapeutics, Haemosonics, Hemosquid, Sanofi and speaker of Takeda, COR2ED. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Likis FE, Sathe NA, Morgans AK, et al. Introduction. In: Management of Postpartum Hemorrhage [Internet] [Internet]. Agency for Healthcare Research and Quality (US); 2015 [cited 2024 Nov 18]. Available online: https://www.ncbi.nlm.nih.gov/books/NBK294453/
2. Van de Velde M, Diez C, Varon AJ. Obstetric hemorrhage. Curr Opin Anaesthesiol 2015;28:186-90. [Crossref] [PubMed]
3. Giouleka S, Tsakiridis I, Kalogiannidis I, et al. Postpartum Hemorrhage: A Comprehensive Review of Guidelines. Obstet Gynecol Surv 2022;77:665-82. [Crossref] [PubMed]
4. Introduction. In: WHO recommendations on the assessment of postpartum blood loss and use of a treatment bundle for postpartum haemorrhage [Internet] [Internet]. World Health Organization; 2023 [cited 2024 Oct 24]. Available online: https://www.ncbi.nlm.nih.gov/books/NBK598984/
5. James AH, Federspiel JJ, Ahmadzia HK. Disparities in obstetric hemorrhage outcomes. Res Pract Thromb Haemost 2022;6:e12656. [Crossref] [PubMed]
6. Practice Bulletin No. 183: Postpartum Hemorrhage. Obstet Gynecol 2017;130:e168-86. [Crossref] [PubMed]
7. Khan KS, Wojdyla D, Say L, et al. WHO analysis of causes of maternal death: a systematic review. Lancet 2006;367:1066-74. [Crossref] [PubMed]
8. Say L, Chou D, Gemmill A, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health 2014;2:e323-33. [Crossref] [PubMed]
9. Bláha J, Bartošová T. Epidemiology and definition of PPH worldwide. Best Pract Res Clin Anaesthesiol 2022;36:325-39. [Crossref] [PubMed]
10. Full Text PDF [Internet]. [cited 2024 Oct 29]. Available online: https://onlinelibrary.wiley.com/doi/pdfdirect/10.1111/1471-0528.14178
11. World Health Organization. WHO recommendations for the prevention and treatment of postpartum haemorrhage [Internet]. Geneva: World Health Organization; 2012:41. [cited 2024 Oct 29]. Available online: https://iris.who.int/handle/10665/75411
12. Li S, Gao J, Liu J, et al. Incidence and Risk Factors of Postpartum Hemorrhage in China: A Multicenter Retrospective Study. Front Med (Lausanne) 2021;8:673500. [Crossref] [PubMed]
13. pph-roadmap.pdf [Internet]. [cited 2025 Feb 28]. Available online: https://cdn.who.int/media/docs/default-source/reproductive-health/maternal-health/pph-roadmap.pdf?utm_source=chatgpt.com
14. Vricella LK, Louis JM, Chien E, et al. Blood volume determination in obese and normal-weight gravidas: the hydroxyethyl starch method. Am J Obstet Gynecol 2015;213:408.e1-6. [Crossref] [PubMed]
15. Omotayo MO, Abioye AI, Kuyebi M, et al. Prenatal anemia and postpartum hemorrhage risk: A systematic review and meta-analysis. J Obstet Gynaecol Res 2021;47:2565-76. [Crossref] [PubMed]
16. Borovac-Pinheiro A, Pacagnella RC, Cecatti JG, et al. Postpartum hemorrhage: new insights for definition and diagnosis. Am J Obstet Gynecol 2018;219:162-8. [Crossref] [PubMed]
17. Rath WH. Postpartum hemorrhage--update on problems of definitions and diagnosis. Acta Obstet Gynecol Scand 2011;90:421-8. [Crossref] [PubMed]
18. Lertbunnaphong T, Lapthanapat N, Leetheeragul J, et al. Postpartum blood loss: visual estimation versus objective quantification with a novel birthing drape. Singapore Med J 2016;57:325-8. [Crossref] [PubMed]
19. Diaz V, Abalos E, Carroli G. Methods for blood loss estimation after vaginal birth. Cochrane Database Syst Rev 2018;9:CD010980. [Crossref] [PubMed]
20. Ziganshin AM, Mudrov VA. Technology for Quantifying the Postpartum Blood Loss. Sovrem Tekhnologii Med 2021;12:71-5. [Crossref] [PubMed]
21. Wearable Sensor Could Detect Postpartum Blood Loss [Internet]. [cited 2024 Oct 24]. Available online: https://www.photonics.com/Articles/Wearable_Sensor_Could_Detect_Postpartum_Blood_Loss/a69365
22. Collier AY, Molina RL. Maternal Mortality in the United States: Updates on Trends, Causes, and Solutions. Neoreviews 2019;20:e561-74. [Crossref] [PubMed]
23. Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division [Internet]. [cited 2024 Oct 31]. Available online: https://www.who.int/publications/i/item/9789240068759
24. Sebghati M, Chandraharan E. An update on the risk factors for and management of obstetric haemorrhage. Womens Health (Lond) 2017;13:34-40. [Crossref] [PubMed]
25. Oberg AS, Hernandéz-Diaź S, Frisell T, et al. Genetic contribution to postpartum haemorrhage in Swedish population: cohort study of 466,686 births. BMJ 2014;g4984. [Crossref] [PubMed]
26. VanderMeulen H, Petrucci J, Floros G, et al. The experience of postpartum bleeding in women with inherited bleeding disorders. Res Pract Thromb Haemost 2019;3:733-40. [Crossref] [PubMed]
27. Colalillo EL, Sparks AD, Phillips JM, et al. Obstetric hemorrhage risk assessment tool predicts composite maternal morbidity. Sci Rep 2021;11:14709. [Crossref] [PubMed]
28. Ende HB. Risk assessment tools to predict postpartum hemorrhage. Best Pract Res Clin Anaesthesiol 2022;36:341-8. [Crossref] [PubMed]
29. Venkatesh KK, Strauss RA, Grotegut CA, et al. Machine Learning and Statistical Models to Predict Postpartum Hemorrhage. Obstet Gynecol 2020;135:935-44. [Crossref] [PubMed]
30. Meyer SR, Carver A, Joo H, et al. External Validation of Postpartum Hemorrhage Prediction Models Using Electronic Health Record Data. Am J Perinatol 2024;41:598-605. [Crossref] [PubMed]
31. Xu Y, Zhu S, Song H, et al. A new modified obstetric early warning score for prognostication of severe maternal morbidity. BMC Pregnancy Childbirth 2022;22:901. [Crossref] [PubMed]
32. Xu Y, Zhu S, Song H, et al. Comparison of the efficacy for early warning systems in predicting obstetric critical illness. Eur J Obstet Gynecol Reprod Biol 2024;296:327-32. [Crossref] [PubMed]
33. McLintock C. Prevention and treatment of postpartum hemorrhage: focus on hematological aspects of management. Hematology Am Soc Hematol Educ Program 2020;2020:542-6. [Crossref] [PubMed]
34. Gill P, Patel A, Van Hook JW. Uterine Atony. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 [cited 2024 Oct 24]. Available online: http://www.ncbi.nlm.nih.gov/books/NBK493238/
35. Atukunda EC, Mugyenyi GR, Obua C, et al. Measuring Post-Partum Haemorrhage in Low-Resource Settings: The Diagnostic Validity of Weighed Blood Loss versus Quantitative Changes in Hemoglobin. PLoS One 2016;11:e0152408. [Crossref] [PubMed]
36. PPH_2nd_edn_Prelims.pdf [Internet]. [cited 2024 Nov 1]. Available online: https://beta.glowm.com/pdf/PPH_2nd_edn_Prelims.pdf
37. Vardar Z, Dupuis CS, Goldstein AJ, et al. Pelvic ultrasonography of the postpartum uterus in patients presenting to the emergency room with vaginal bleeding and pelvic pain. Ultrasonography 2022;41:782-95. [Crossref] [PubMed]
38. Uyoga S, George EC, Bates I, et al. Point-of-care haemoglobin testing in African hospitals: a neglected essential diagnostic test. Br J Haematol 2021;193:894-901. [Crossref] [PubMed]
39. WHO Recommendations for the Prevention and Treatment of Postpartum Haemorrhage [Internet]. Geneva: World Health Organization; 2012 [cited 2024 Nov 1]. (WHO Guidelines Approved by the Guidelines Review Committee). Available online: http://www.ncbi.nlm.nih.gov/books/NBK131942/
40. Collado ZC. Challenges in public health facilities and services: evidence from a geographically isolated and disadvantaged area in the Philippines. J Glob Health Rep 2019;3:e2019059.
41. Coughlin SS, Clary C, Johnson JA, et al. Continuing Challenges in Rural Health in the United States. J Environ Health Sci 2019;5:90-2.
42. Gonzalez-Fiol A, Fardelmann KL, Yanez D, et al. Comparison between the Rotational Thromboelastometry (ROTEM) Delta device against the Cartridge-based Thromboelastography 6s and Quantra in a healthy third trimester pregnant cohort. J Clin Monit Comput 2023;37:267-73. [Crossref] [PubMed]
43. Nath SS, Pandey CK, Kumar S. Clinical application of viscoelastic point-of-care tests of coagulation-shifting paradigms. Ann Card Anaesth 2022;25:1-10. [Crossref] [PubMed]
44. Kim SM, Sohn CH, Kwon H, et al. Thromboelastography as an early prediction method for hypofibrinogenemia in emergency department patients with primary postpartum hemorrhage. Scand J Trauma Resusc Emerg Med 2024;32:85. [Crossref] [PubMed]
45. Baulig W, Akbas S, Schütt PK, et al. Comparison of the resonance sonorheometry based Quantra® system with rotational thromboelastometry ROTEM® sigma in cardiac surgery - a prospective observational study. BMC Anesthesiol 2021;21:260. [Crossref] [PubMed]
46. Amgalan A, Allen T, Othman M, et al. Systematic review of viscoelastic testing (TEG/ROTEM) in obstetrics and recommendations from the women's SSC of the ISTH. J Thromb Haemost 2020;18:1813-38. [Crossref] [PubMed]
47. Khanna P, Sinha C, Singh AK, et al. The role of point of care thromboelastography (TEG) and thromboelastometry (ROTEM) in management of Primary postpartum haemorrhage: A meta-analysis and systematic review. Saudi J Anaesth 2023;17:23-32. [Crossref] [PubMed]
48. Deppe AC, Weber C, Zimmermann J, et al. Point-of-care thromboelastography/thromboelastometry-based coagulation management in cardiac surgery: a meta-analysis of 8332 patients. J Surg Res 2016;203:424-33. [Crossref] [PubMed]
49. Chauncey JM, Wieters JS. Tranexamic Acid. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 [cited 2024 Dec 3]. Available online: http://www.ncbi.nlm.nih.gov/books/NBK532909/
50. 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. Lancet 2017;389:2105-16. [Crossref] [PubMed]
51. The effect of tranexamic acid on postpartum bleeding in women with moderate and severe anaemia (WOMAN-2): an international, randomised, double-blind, placebo-controlled trial. Lancet 2024;404:1645-56. [Crossref] [PubMed]
52. Wikkelsø AJ, Edwards HM, Afshari A, et al. Pre-emptive treatment with fibrinogen concentrate for postpartum haemorrhage: randomized controlled trial. Br J Anaesth 2015;114:623-33. [Crossref] [PubMed]
53. Abrahamyan L, Tomlinson G, Callum J, et al. Cost-effectiveness of Fibrinogen Concentrate vs Cryoprecipitate for Treating Acquired Hypofibrinogenemia in Bleeding Adult Cardiac Surgical Patients. JAMA Surg 2023;158:245-53. [Crossref] [PubMed]
54. Collins PW, Cannings-John R, Bruynseels D, et al. Viscoelastometric-guided early fibrinogen concentrate replacement during postpartum haemorrhage: OBS2, a double-blind randomized controlled trial. Br J Anaesth 2017;119:411-21. [Crossref] [PubMed]
55. Ahmadzia HK, Hynds EB, Amdur RL, et al. National trends in tranexamic acid use in the peripartum period, 2015-2019. J Thromb Thrombolysis 2020;50:746-52. [Crossref] [PubMed]
56. Sentilhes L, Madar H, Le Lous M, et al. Tranexamic acid for the prevention of blood loss after cesarean among women with twins: a secondary analysis of the TRAnexamic Acid for Preventing Postpartum Hemorrhage Following a Cesarean Delivery randomized clinical trial. Am J Obstet Gynecol 2022;227:889.e1-889.e17. [Crossref] [PubMed]
57. Pacheco LD, Clifton RG, Saade GR, et al. Tranexamic Acid to Prevent Obstetrical Hemorrhage after Cesarean Delivery. N Engl J Med 2023;388:1365-75. [Crossref] [PubMed]
58. Tranexamic acid for postpartum bleeding: a systematic review and individual patient data meta-analysis of randomised controlled trials - The Lancet [Internet]. [cited 2024 Nov 4]. Available online: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)02102-0/fulltext
59. Rigouzzo A, Froissant PA, Louvet N. Changing hemostatic management in post-partum hemorrhage. Am J Hematol 2024;99:S13-8. [Crossref] [PubMed]
60. Wang Y, Xiao C, Zhang N, et al. Performance of Bakri balloon tamponade in controlling postpartum hemorrhage. Am J Transl Res 2023;15:2268-79.
61. Shields LE, Klein C, Torti J, et al. Effectiveness of the Intrauterine Balloon Tamponade Compared With an Intrauterine, Vacuum-Induced, Hemorrhage-Control Device for Postpartum Hemorrhage. Obstet Gynecol 2025;145:65-71. [Crossref] [PubMed]
62. Phillips JM, Sakamoto S, Buffie A, et al. How do I perform cell salvage during vaginal obstetric hemorrhage? Transfusion 2022;62:1159-65. [Crossref] [PubMed]
63. Anger HA, Dabash R, Durocher J, et al. The effectiveness and safety of introducing condom-catheter uterine balloon tamponade for postpartum haemorrhage at secondary level hospitals in Uganda, Egypt and Senegal: a stepped wedge, cluster-randomised trial. BJOG 2019;126:1612-21. [Crossref] [PubMed]
64. Weeks AD, Akinola OI, Amorim M, et al. World Health Organization Recommendation for Using Uterine Balloon Tamponade to Treat Postpartum Hemorrhage. Obstet Gynecol 2022;139:458-62. [Crossref] [PubMed]
65. Moleiro ML, Braga J, Machado MJ, et al. Uterine Compression Sutures in Controlling Postpartum Haemorrhage: A Narrative Review. Acta Med Port 2022;35:51-8. [Crossref] [PubMed]
66. Rodriguez MI, Jensen JT, Gregory K, et al. A novel tamponade agent for management of post partum hemorrhage: adaptation of the Xstat mini-sponge applicator for obstetric use. BMC Pregnancy Childbirth 2017;17:187. [Crossref] [PubMed]
67. Rodriguez MI, Bullard M, Jensen JT, et al. Management of Postpartum Hemorrhage With a Mini-Sponge Tamponade Device. Obstet Gynecol 2020;136:876-81. [Crossref] [PubMed]
68. Phillips JM, Eppes C, Rodriguez M, et al. Traditional uterine tamponade and vacuum-induced uterine tamponade devices in obstetrical hemorrhage management. Am J Obstet Gynecol MFM 2023;5:100739. [Crossref] [PubMed]
69. Fein S. Efficacy, Safety, and Tolerability of Iron Infusions in Pregnant Women: A Retrospective Chart Review. In ASH; 2023 [cited 2024 Nov 4]. Available online: https://ash.confex.com/ash/2023/webprogram/Paper185521.html
70. Thiele LR, Duryea EL, Ragsdale AS, et al. Direct Dispensation of Prenatal Supplements With Iron and Anemia Among Pregnant People. JAMA Netw Open 2023;6:e2332100. [Crossref] [PubMed]
71. Anaemia in women and children [Internet]. [cited 2024 Nov 4]. Available online: https://www.who.int/data/gho/data/themes/topics/anaemia_in_women_and_children
72. Global anaemia reduction efforts among women of reproductive age: impact, achievement of targets and the way forward for optimizing efforts [Internet]. [cited 2024 Nov 4]. Available online: https://www.who.int/publications/i/item/9789240012202
73. Iyer NS, Khanuja K, Roman A, et al. Use of cell salvage at the time of cesarean delivery: a meta-analysis of randomized controlled trials. Am J Obstet Gynecol MFM 2024;6:101257. [Crossref] [PubMed]