ACOG Expands Recommendations to Treat Postpartum Hemorrhage

Washington, DC—The American College of Obstetricians and Gynecologists (ACOG) today released expanded guidance on postpartum hemorrhage—the leading cause of maternal mortality worldwide—to include recommendations for standard, hospital-wide protocols, as well as potential treatments.

While maternal mortality rates due to postpartum hemorrhage have decreased in the last four decades it still accounts for more than 10 percent of pregnancy-related deaths. Postpartum hemorrhage is excessive bleeding (1,000 mL or greater) within the first 24 hours after birth but can occur up to 12 weeks postpartum. While there can be several causes, uterine atony, or when the uterus fails to contract after delivery, accounts for 70-80 percent of cases and should usually be considered first.

ACOG recommends that all hospitals put organized, systematic processes in place to help coordinate the response and management of postpartum hemorrhage. In an effort to reduce rates of maternal mortality and morbidity nationwide, ACOG partners with 24 organizations to implement the Alliance for Innovation on Maternal Health (AIM), which includes the implementation of consistent maternity care practices for several conditions including obstetric hemorrhage. Today, 13 states and three health networks, representing 1.5 million births, are active participants.

"The important thing is for providers to be able to recognize the signs and symptoms of excessive blood loss earlier and to have the resources at hand for the prompt escalation to more aggressive interventions if other therapies fail," said Aaron Caughey, M.D., Ph.D., one of the authors of the updated Practice Bulletin and professor and chair of Obstetrics and Gynecology at Oregon Health & Science University.

Multidisciplinary teams, including physicians, nurses and midwives, should be trained to implement key elements in four categories, including readiness to respond; recognition and prevention measures; multidisciplinary response; and data reporting and systematic learning, including drills like simulation-based training.

"By implementing standard protocols, we can improve outcomes," Caughey said. "And this is even more critical for rural hospitals that often do not have the ability to treat a woman who may need a massive blood transfusion. They need to have a response plan in place for these obstetric emergencies, which includes triage and transferring patients to higher-level facilities, if necessary."

Risk assessment tools can help identify whether a woman is likely to experience excessive bleeding, and includes factors such as lacerations, retained placenta and abnormally adherent placenta, known as placenta accreta. With regard to the latter, an ob-gyn should have high suspicion for this condition, particularly in the presence of placenta previa and a prior cesarean delivery.

In an effort to reduce the incidence of postpartum hemorrhage, there are three components for active management of the third stage of labor: oxytocin administration, uterine massage and umbilical cord traction. Uterotonics, agents used to contract the uterus, should be the first-line treatment for postpartum hemorrhage caused by uterine atony, although the specific agent is up to the provider's discretion.

Other medical and surgical approaches to treat postpartum hemorrhage include intrauterine balloons and tranexamic acid. Tranexamic acid, which prevents blood clots from breaking down, can be administered when initial therapies fail and has been shown to reduce mortality when given within three hours of birth.

"Less invasive methods should always be used first," said Caughey. "If those methods fail, then more aggressive interventions must be considered to preserve the life of the mother."

The Practice Bulletin #183, "Postpartum Hemorrhage" will be published in the October issue of Obstetrics and Gynecology.

Other recommendations issued in the October Obstetrics & Gynecology

Committee Opinion #721, "Smoking Cessation During Pregnancy"
Smoking is the one of the most important modifiable causes of poor pregnancy outcomes in the United States, and is associated with maternal, fetal, and infant morbidity and mortality. The physical and psychologic addiction to cigarettes is powerful; however, the compassionate intervention of the obstetrician– gynecologist can be the critical element in prenatal smoking cessation. An office-based protocol that systematically identifies pregnant women who smoke and offers treatment or referral has been proved to increase quit rates. A short counseling session with pregnancy-specific educational materials and a referral to the smokers' quit line is an effective smoking cessation strategy. The 5A's is an office-based intervention developed to be used under the guidance of trained practitioners to help pregnant women quit smoking. Knowledge of the use of the 5A's, health care support systems, and pharmacotherapy add to the techniques providers can use to support perinatal smoking cessation. The use of alternative forms of nicotine, such as e-cigarettes and vaping, have increased substantially in recent years, but there are little data regarding the health effects of these agents, either in the general population or in pregnant women specifically.

Committee Opinion #722, "Marijuana Use During Pregnancy and Lactation"
Cannabis sativa (marijuana) is the illicit drug most commonly used during pregnancy. The self-reported prevalence of marijuana use during pregnancy ranges from 2% to 5% in most studies. A growing number of states are legalizing marijuana for medicinal or recreational purposes, and its use by pregnant women could increase even further as a result. Because of concerns regarding impaired neurodevelopment, as well as mater-nal and fetal exposure to the adverse effects of smoking, women who are pregnant or contemplating pregnancy should be encouraged to discontinue marijuana use. Obstetrician–gynecologists should be discouraged from pre-scribing or suggesting the use of marijuana for medicinal purposes during preconception, pregnancy, and lactation. Pregnant women or women contemplating pregnancy should be encouraged to discontinue use of marijuana for medicinal purposes in favor of an alternative therapy for which there are better pregnancy-specific safety data. There are insufficient data to evaluate the effects of marijuana use on infants during lactation and breastfeeding, and in the absence of such data, marijuana use is discouraged.

Committee Opinion #723, "Guidelines for Diagnostic Imaging During Pregnancy and Lactation"
Imaging studies are important adjuncts in the diagnostic evaluation of acute and chronic condi-tions. However, confusion about the safety of these modalities for pregnant and lactating women and their infants often results in unnecessary avoidance of useful diagnostic tests or the unnecessary interruption of breastfeeding. Ultrasonography and magnetic resonance imaging are not associated with risk and are the imaging techniques of choice for the pregnant patient, but they should be used prudently and only when use is expected to answer a relevant clinical question or otherwise provide medical benefit to the patient. With few exceptions, radiation exposure through radiography, computed tomography scan, or nuclear medicine imaging techniques is at a dose much lower than the exposure associated with fetal harm. If these techniques are necessary in addition to ultra-sonography or magnetic resonance imaging or are more readily available for the diagnosis in question, they should not be withheld from a pregnant patient. Breastfeeding should not be interrupted after gadolinium administration.

The American College of Obstetricians and Gynecologists (The College), a 501(c)(3) organization, is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of more than 58,000 members, The College strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. The American Congress of Obstetricians and Gynecologists (ACOG), a 501(c)(6) organization, is its companion organization. www.acog.org