More can be done to prevent excessive bleeding after childbirth, including training for maternity staff and the development of local protocols, state revised clinical guidelines published today by the Royal College of Obstetricians and Gynaecologists (RCOG).
A new study also published today in BJOG: An International Journal of Obstetrics and Gynaecology (BJOG) suggests that assisted reproductive technology (ART) could be associated with an increased risk of severe postpartum haemorrhage (PPH), in particular amongst multiple pregnancies.
The 2012-2014 Confidential Enquiries into Maternal Deaths and Morbidity report, published last week, identifies 13 deaths from haemorrhage making it the third leading cause of direct maternal death in the UK. This new guideline provides advice for healthcare professionals on preventing and treating postpartum haemorrhage (PPH) in order to further reduce the number of women who die from the condition.
PPH is defined as losing 500ml of blood within 24 hours of childbirth. Excessive bleeding can also occur up to 12 weeks postnatally, known as secondary PPH.
The guideline states that although in most cases there are no identifiable risk factors, some of the risk factors for PPH include; pre-existing blood disorders, multiple pregnancy, previous PPH, pre-eclampsia, problems associated with the placenta, anaemia, a large baby, prolonged labour, vaginal tears, episiotomy and general anaesthetic. The most common cause of PPH is when the uterus fails to contract.
With regards to treating PPH, a combination of pharmacological, mechanical and surgical methods may need to be used to stop the bleeding. In the most severe cases, a hysterectomy might need to be performed to control the bleeding.
The guideline highlights that communication is crucial and any woman at-risk of PPH should be advised to give birth in a hospital with a blood bank on site. PPH can occur unexpectedly and can be very stressful for a woman and her partner. Wherever possible, they should be kept informed and reassured at all times.
The guideline also emphasises the need for every maternity unit in the UK to have a protocol in place to treat a woman with PPH. Training for all maternity staff, including rehearsals to manage the situation is critical.
Dr Andrew Thomson, consultant obstetrician and co-chair of the RCOG Guidelines Committee, said:
“PPH is an obstetric emergency therefore all staff involved in maternity care should have appropriate training in treating women who bleed excessively after childbirth.
“Although relatively rare in the UK, there has been no significant reduction in the number of women dying from obstetric haemorrhage since 2009. These guidelines, which should be adopted by all obstetric-led units in the country, provide clinicians with best-practice advice and guidance on preventing and treating the condition.”
The BJOG study was conducted in Norway and included all women admitted for delivery at Oslo
University Hospital and Drammen Hospital between 2008 and 2011. It included 1064 cases of severe PPH, defined as blood loss of more than 1500ml or need for a blood transfusion. The control group consisted of a random sample of all deliveries without severe PPH from the same source population, comprising of 2059 deliveries.
The researchers looked at the association between ART and severe PPH and found that there was a link. In the severe PPH group, 10.8 % of the pregnancies were conceived by ART, in comparison to 4.0 % in the control group. The study also found that the link was stronger in multiple pregnancies. Women with the combination of an ART pregnancy and multiples were considerably higher among the cases of severe PPH (4.5 %) than among the women in the control group (0.3 %).
In conclusion, the researchers recommend the use of single embryo transfer to reduce the multiple birth rate and emphasise the importance of offering couples embarking on treatment information about the possible risks of PPH.
Commenting on the study, Professor Adam Balen, spokesperson for the Royal College of Obstetricians and Gynaecologists (RCOG) and Chair of the British Fertility Society (BFS) said:
“Further research into factors leading to severe PPH amongst women undergoing fertility treatment seems warranted.
“There has been a big drive to increase the use of elective transfer of a single embryo in IVF to reduce the rate of multiple pregnancy, which can have pose a serious health risk both to the mother and baby.”
For media enquiries, case studies and copies of the guideline, please contact the RCOG press office on 020 7772 6444 or email firstname.lastname@example.org
This is the second edition of this guideline, which was published in 2009.
New information for women on preventing excessive bleeding after birth is also published today.
The 2012-2014 Confidential Enquiries into Maternal Death and Morbidity was recently published at www.npeu.ox.ac.uk.
Reference: Assisted reproductive technology and severe postpartum haemorrhage: a case–control study. LT Nyfløt, I Sandven, NB Oldereid, B Stray-Pedersen, S Vangen. BJOG 2016; 10.1111/1471-0528.14471
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The Royal College of Obstetricians and Gynaecologists is a medical charity that champions the provision of high quality women’s healthcare in the UK and beyond. It is dedicated to encouraging the study and advancing the science and practice of obstetrics and gynaecology. It does this through postgraduate medical education and training and the publication of clinical guidelines and reports on aspects of the specialty and service provision.