{
  "abstract": "Introduction Obstetric haemorrhage is a significant worldwide concern. This year, quoting 2023 data, the WHO listed severe haemorrhage as a leading cause of maternal mortality, mainly in low and lower-middle income countries. 1 Haemorrhage is also an important cause of maternal deaths in high income countries. For example, the United Kingdom reports haemorrhage as the joint second commonest, direct cause of maternal mortality between 2020 – 2022, together with suicide and sepsis,2 and it has also been identified as the single leading cause of peri-operative cardiac arrest in obstetric patients.3 Therefore, it is essential that obstetric haemorrhage is prevented, recognized, and treated in a professional, multidisciplinary and efficient manner.The Helsinki Declaration on Patient Safety in Anaesthesiology4 requires that institutions have protocols and facilities for managing massive haemorrhage. The World Health Organization has published recommendations for the prevention and treatment of postpartum haemorrhage (PPH)5 and defines this as blood loss of 500 ml or more within 24 hours after birth, with severe PPH above 1000 ml in the same period. Guideline-driven management of obstetric haemorrhage allows a planned and coordinated approach to this global problem, and many countries have developed such national guidelines.5 Prevention Strong recommendations from the WHO include the use of uterotonics, specifically oxytocin as first line, for the active management of the third stage of labour for all deliveries including caesarean sections; delayed cord clamping for at least one minute after birth; and controlled cord traction for placenta removal during caesarean section 6 for PPH prevention. In addition, the Irish Institute of Obstetricians and Gynaecologists, in their national clinical practice guideline, advise an antenatal or intrapartum risk assessment for all women, that includes haemoglobin and platelet levels, to identify at-risk women early.7 The Royal College of Obstetricians and Gynaecologists also recommends that such high-risk women should only be delivered in a hospital which has an on-site blood bank,8 and that any identified antenatal anaemia should be appropriately investigated and treated.8 Oral iron is the suggested option for iron-deficiency anaemia,9 with intravenous iron reserved for cases of intolerance, poor compliance, or a lack of time.9 In contrast, there is limited evidence to support any interventions directed at the prevention of antepartum haemorrhage (APH),10 though modifiable risk factors such as smoking and drug misuse have been implicated10 and should be identified and addressed early.Recognition Obstetric haemorrhage, whether antepartum or postpartum, needs to be identified early for optimal management and outcomes. Visual estimation of blood loss during obstetric haemorrhage is often inaccurate, 8 11 and therefore, blood loss should be quantitatively and cumulatively measured.5 7 A Welsh study demonstrated that this is possible in all hospitals and that measurement of blood loss is associated with a higher rate of identification of PPH.12 Furthermore, the patient’s clinical signs and symptoms during blood loss are an essential part of the assessment.7 8 Charting parameters on a modified obstetric early warning score chart gives a visual representation of the progression of the clinical situation and of its severity.13 14 The cause of the obstetric haemorrhage should also be identified for example, placenta previa or abruption in APH, or uterine atony, retained tissue, trauma or coagulopathy in PPH, to allow targeted treatment.Treatment Managing obstetric haemorrhage requires treatment of the underlying cause concurrently with general haemodynamic and coagulation support, especially in the case of hypovolemic haemorrhagic shock, by well-trained multidisciplinary teams.The commonest aetiology for PPH is uterine atony. In this case, first-line treatment includes intravenous oxytocin1 5 7 15 as an initial bolus, followed by an infusion. Carbetocin has been identified as a possible alternative to oxytocin.16 Recommended second- and third-line uterotonics are the ergot alkaloids1 5 7 16 such as ergometrine and ergonovine, and prostaglandins1 5 7 16 including carboprost, sulprostone, and misoprostol. If these measures are unsuccessful, intrauterine balloon tamponade, uterine artery embolization, and even hysterectomy may be required.8 Haemodynamic support in obstetric haemorrhage includes isotonic crystalloids in preference to colloids for initial resuscitation,1 and transfusion of blood products in line with local protocols,9 which may be empirical ratio-based,5 laboratory-result guided,5 or dependent on point-of-care tests.17 It is very important that administered fluids are warmed,18 and cell salvage can be considered.5 7 8 Vasopressors may be required to support the circulation in these circumstances but should not be seen as a substitute to appropriate intravascular volume replacement.3 Coagulopathy may be the cause, or occur as a result, of massive haemorrhage. Tranexamic acid is recommended for clot stabilization, with greatest mortality benefit observed when given within three hours of delivery.19 Both viscoelastic testing, and laboratory levels, can guide replacement of platelets, fibrinogen, and coagulation factors. Platelet transfusion thresholds vary, but most guidelines would recommend administration of platelets to maintain a level above 50–75 x109/l5 7– 9 15 although thrombocytopenia during PPH was found to be an uncommon occurrence.20 Fibrinogen replacement is recommended to maintain a laboratory level >2 g/l5 7 8 15 21, and viscoelastic testing can support early goal-directed fibrinogen replacement when FIBTEM A5 is less than 12 mm (equivalent to Claus fibrinogen ≤2 g/l).20 21 Recombinant activated factor VII (rFVIIa) has also been considered in the context of obstetric haemorrhage, though most guidelines recommend its use only in life-threatening scenarios due to concerns about off-label use, cost, efficacy, and adverse effects.5 22 Should cardiac arrest occur in the context of massive PPH, the standard adult advanced life support algorithm is to be followed including attention to Hypovolemia as a reversible cause, as part of the 4Hs and 4Ts approach.23 Some pregnancy-specific modifications include left lateral tilt or manual uterine displacement to avoid aortocaval compression; consideration of peri-mortem caesarean section; and early intubation.23 The European Resuscitation Council will issue new guidelines in October 2025 and drafts available indicate an increased attention to pregnancy as a special circumstance in cardiac arrest.24 This novel focus includes a new maternal cardiac arrest algorithm; an emphasis on intravascular and/or intraosseous access being achieved above the level of the diaphragm; and an introduction of the 4Ps as pregnancy-specific causes of cardiac arrest.24 Finally, many guidelines emphasize the importance of multidisciplinary patient care,5 7 8 17 and advise simulation-based training1 5 7 8 17 to enhance preparedness in the guideline-driven management of obstetric haemorrhage.Conclusion Having a locally adapted, evidence based, and updated guideline to direct the management of obstetric haemorrhage allows for a planned, practiced, and coordinated response to this emergency, which will help to contribute to the reduction of patient morbidity and mortality from blood loss.References WHO. Maternal Mortality. Published 7th April 2025. Accessed at: https://www.who.int/news-room/fact-sheets/detail/maternal-mortality MBRRACE-UK. Maternal Mortality 2020 – 2022, October 2024 Update. Last Updated January 2025 (v.11). Accessed at: https://www.npeu.ox.ac.uk/mbrrace-uk/data-brief/maternal-mortality-2020-2022#causes-of-maternal-deaths-uk-2020-2022 Lucas DN, Kursumovic E, Cook TM, Kane AD, Armstrong RA, Plaat F, Soar J. Cardiac arrest in obstetric patients receiving anaesthetic care: results from the 7th national audit project of the royal college of anaesthetists. Anaesthesia 2024 May;79(5):514–23.Mellin-Olsen J, Staender S, Whitaker DK, Smith AF. The Helsinki declaration on patient safety in anaesthesiology. European Journal of Anaesthesiology| EJA. 2010 Jul 1;27(7):592–7.de Vries PL, Deneux-Tharaux C, Baud D, Chen KK, Donati S, Goffinet F, Knight M, D’Souzah R, Sueters M, van den Akker T. Postpartum haemorrhage in high-resource settings: variations in clinical management and future research directions based on a comparative study of national guidelines. BJOG: An International Journal of Obstetrics & Gynaecology 2023 Dec;130(13):1639–52.WHO Guidelines Approved by the Guidelines Review Committee. WHO recommendations for the prevention and treatment of postpartum haemorrhage. Geneva: World Health Organization. 2012.Byrne B, Spring A, Barrett N, Power J, Mckernan J, Brophy D. National clinical practice guideline: prevention and management of primary postpartum haemorrhage. National Women and Infants Health Programme and The Institute of Obstetricians and Gynaecologists. 2022.Mavrides E, Allard S, Chandraharan E, Collins P, Green L, Hunt BJ, Riris S, Thomson AJ, on behalf of the Royal College of Obstetricians and Gynaecologists. Prevention and management of postpartum haemorrhage. BJOG. 2016;124:e106–e149.Green L, Connolly C, Cooper TK, Cho G, Allard S. Blood transfusion in obstetrics. Green-Top Guideline No. 47 Royal College of Obstetricians and Gynaecologists. 2007.Thomson A, Ramsay J, Rich D. Antepartum Haemorrhage. Green Top Guideline No. 63. Royal College of Obstetricians and Gynaecologists. 2011.Bose P, Regan F, Paterson-Brown S. Improving the accuracy of estimated blood loss at obstetric haemorrhage using clinical reconstructions. BJOG: An International Journal of Obstetrics & Gynaecology 2006 Aug;113(8):919–24.Bell SF, Watkins A, John M, Macgillivray E, Kitchen TL, James D, Scarr C, Bailey CM, Kelly KP, James K, Stevens JL. Incidence of postpartum haemorrhage defined by quantitative blood loss measurement: a national cohort. BMC pregnancy and childbirth. 2020 Dec;20:1–9.Umar A, Ameh CA, Muriithi F, Mathai M. Early warning systems in obstetrics: a systematic literature review. PloS one. 2019 May 31;14(5):e0217864.Pezdirc N, Pintarič TS, Lučovnik M. Obstetric-specific compared to general early warning system for predicting severe postpartum maternal morbidity. Biomolecules and Biomedicine. 2025.Drew T, Carvalho JC. Major obstetric haemorrhage. BJA education. 2022 Jun 1;22(6):238–44.Heesen M, Carvalho B, Carvalho JC, Duvekot JJ, Dyer RA, Lucas DN, McDonnell N, Orbach-Zinger S, Kinsella SM. International consensus statement on the use of uterotonic agents during caesarean section. Anaesthesia 2019 Oct;74(10):1305–19.Hofer S, Blaha J, Collins PW, Ducloy-Bouthors AS, Guasch E, Labate F, Lança F, Nyfløt LT, Steiner K, Van de Velde M. Haemostatic support in postpartum haemorrhage: a review of the literature and expert opinion. European Journal of Anaesthesiology| EJA. 2023 Jan 1;40(1):29–38.Bamber J, Lucas N, Knight M, on behalf of the MBRRACE-UK anaesthesia chapter writing group. Messages for anaesthetic care. In: M Knight, M Nair, D Tuffnell, J Shakespeare, S Kenyon, JJ Kurinczuk, on behalf of MBRRACE-UK, eds. Saving Lives, Improving Mothers’ Care - Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2013 –15. Oxford: National Perinatal Epidemiology Unit, University of Oxford, 2017:67–73.Shakur H, Roberts I, Fawole B, Chaudhri R, El-Sheikh M, Akintan A, Qureshi Z, Kidanto H, Vwalika B, Abdulkadir A, Etuk S. 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. The Lancet 2017 May 27;389(10084):2105–16.Collins PW, Bell SF, De Lloyd L, Collis RE. Management of postpartum haemorrhage: from research into practice, a narrative review of the literature and the cardiff experience. International journal of obstetric anesthesia 2019 Feb 1;37:106–17.de Lloyd LJ, Bell SF, Roberts T, Pereira JF, Bray M, Kitchen T, James D, Collins PW, Collis RE. Early viscoelastometric guided fibrinogen replacement combined with escalation of clinical care reduces progression in postpartum haemorrhage: a comparison of outcomes from two prospective observational studies. International Journal of Obstetric Anesthesia 2024 Aug 1;59:104209.Welsh A, McLintock C, Gatt S, Somerset D, Popham P, Ogle R. Guidelines for the use of recombinant activated factor VII in massive obstetric haemorrhage. Australian and New Zealand Journal of Obstetrics and Gynaecology 2008 Feb;48(1):12–6.Lott C, Truhlář A, Alfonzo A, Barelli A, González-Salvado V, Hinkelbein J, Nolan JP, Paal P, Perkins GD, Thies KC, Yeung J. European resuscitation council guidelines 2021: cardiac arrest in special circumstances. Resuscitation 2021 Apr 1;161:152–219.Lott C, Karageorgos V, Abelairaz-Gomez C, Aird R, Alfonzo A, Bierens J, Cantellow S, Debaty G, Einav S, Fischer M, Gonzalez Salvado V, Grief R, Metelmann B, Metelmann C, Meyer T, Paal P, Peran D, Scapigliati A, Spartinou A, Thies K, Truhlar A, Deakins C, ERC Special Circumstances in Resuscitation Collaborator Group. Draft European Resuscitation Council Guidelines 2025: Special Circumstances in Resuscitation. Accessed in June 2025 at: https://cprguidelines.eu/assets/posters/ERC-Guidelines-2025-Special-Circumstances-final-for-public-comments.pdf",
  "authors": [
    {
      "affiliations": [
        "Department of Anaesthesia, Intensive Care and Pain – Mater Dei Hospital, Msida, Malta, Europe"
      ],
      "name": "Petramay Attard Cortis"
    }
  ],
  "title": "FT13 Guideline driven management of obstetric haemorrhage",
  "uid": "60dd48f6-3e21-53a5-b083-91c5776cbf66"
}