Peripartum Haemorrhage, Diagnosis and Therapy. Guideline of the DGGG, OEGGG and SGGG (S2k Level, AWMF Registry No. 015/063, March 2016)

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. 2018 Apr 26;78(4):382–399. doi: 10.1055/a-0582-0122

Consensus-based Recommendation 9.E34
Maintain or achieve haemodynamic stability and normovolaemia: myocardiac ischaemia with reduced contractility is often present when Hb values ≤ 6 g/dl (3.726 mmol/l) with or without haemodynamic abnormality (RR _sys < 90 mmHg and/or RR _dia < 50 mmHg and/or HR ≥ 115/min) 122 , 123 . Timely call for expert assistance is recommended for uncontrolled blood loss of more than 500 ml following vaginal delivery or more than 1000 ml following Caesarean section and is essential if blood loss is more than 1500 ml 29 , 89 , 95 , 124 . For patients receiving regional anaesthesia (spinal anaesthesia, epidural anaesthesia): if blood loss is ≥ 1500 – 2000 ml and there are signs of persistent bleeding: secure the airway and ensure sufficient oxygen supply ; if necessary, perform early intubation after consultation with the surgeon 125 . If there is a loss of protective reflexes, endotracheal intubation to secure the airway and ensure sufficient oxygenation must take priority. Place wide-diameter access points (2× ≥ 16 G) followed by arterial blood pressure measurement, if necessary even before intubation. A wide-diameter central access (≥ 9 Fr) is recommended 125 , 126 , 127 , 128 . Cell saver blood (official recommendations of CMACE, NICE, OAA/AAGBI, ESA): use of mechanical autotransfusion in patients undergoing elective Caesarean section (e.g. in cases with placenta increta/percreta) can reduce the administration of allogenic blood postoperatively and the duration of hospital stay 129 , 130 . In the emergency setting of PPH the following caveats must be taken into consideration: should only be used, after amniotic fluid removal and delivery of the neonate. Cell-saver blood does not contain clotting factors or platelets. Coagulation factors should be substituted to prevent coagulopathy when administering high transfusion volumes 131 . Cases of hypotension have been reported following the re-transfusion of cell-saver blood with a leukocyte depletion filter 132 . Target values in haemodynamic therapy for “healthy” pregnant women and strong bleeding: After cord clamping, hypotensive resuscitation until surgical haemostasis is achieved with restrictive fluid therapy 133 , 134 . “Normal recapillarisation time” or “palpable radial pulse” are the target values for volume replacement therapy 135 , 136 Goal: MAP > 65 mmHg or lower 137 or RR _sys ~ 90 mmHg 138 . Target Hb: indication for blood transfusion until surgical haemostasis: 7 g/dl (4.347 mmol/l); after surgical haemostasis and successful treatment of the underlying pathology: 7 – 9 g/dl (4.347 – 5.589 mmol/l) 23 , 134 , 138 . Note: ensure sufficient additional iron supplementation on the ward postoperatively. Pharmacological thromboprophylaxis within 24 hours after the pathology causing the bleeding has been treated 134 .

Consensus-based Recommendation 9.E34

Expert consensus

Level of consensus +++

Maintain or achieve haemodynamic stability and normovolaemia: myocardiac ischaemia with reduced contractility is often present when Hb values ≤ 6 g/dl (3.726 mmol/l) with or without haemodynamic abnormality (RR _sys < 90 mmHg and/or RR _dia < 50 mmHg and/or HR ≥ 115/min) 122 , 123 .
Timely call for expert assistance is recommended for uncontrolled blood loss of more than 500 ml following vaginal delivery or more than 1000 ml following Caesarean section and is essential if blood loss is more than 1500 ml 29 , 89 , 95 , 124 .
For patients receiving regional anaesthesia (spinal anaesthesia, epidural anaesthesia): if blood loss is ≥ 1500 – 2000 ml and there are signs of persistent bleeding: secure the airway and ensure sufficient oxygen supply ; if necessary, perform early intubation after consultation with the surgeon 125 . If there is a loss of protective reflexes, endotracheal intubation to secure the airway and ensure sufficient oxygenation must take priority.
Place wide-diameter access points (2× ≥ 16 G) followed by arterial blood pressure measurement, if necessary even before intubation. A wide-diameter central access (≥ 9 Fr) is recommended 125 , 126 , 127 , 128 .
Cell saver blood (official recommendations of CMACE, NICE, OAA/AAGBI, ESA): use of mechanical autotransfusion in patients undergoing elective Caesarean section (e.g. in cases with placenta increta/percreta) can reduce the administration of allogenic blood postoperatively and the duration of hospital stay 129 , 130 . In the emergency setting of PPH the following caveats must be taken into consideration: should only be used, after amniotic fluid removal and delivery of the neonate.
- Cell-saver blood does not contain clotting factors or platelets. Coagulation factors should be substituted to prevent coagulopathy when administering high transfusion volumes 131 .
- Cases of hypotension have been reported following the re-transfusion of cell-saver blood with a leukocyte depletion filter 132 .
Target values in haemodynamic therapy for “healthy” pregnant women and strong bleeding:
- After cord clamping, hypotensive resuscitation until surgical haemostasis is achieved with restrictive fluid therapy 133 , 134 .
- “Normal recapillarisation time” or “palpable radial pulse” are the target values for volume replacement therapy 135 , 136
- Goal: MAP > 65 mmHg or lower 137 or RR _sys ~ 90 mmHg 138 .
- Target Hb: indication for blood transfusion until surgical haemostasis: 7 g/dl (4.347 mmol/l); after surgical haemostasis and successful treatment of the underlying pathology: 7 – 9 g/dl (4.347 – 5.589 mmol/l) 23 , 134 , 138 . Note: ensure sufficient additional iron supplementation on the ward postoperatively.
Pharmacological thromboprophylaxis within 24 hours after the pathology causing the bleeding has been treated 134 .