Peripartum Haemorrhage, Diagnosis and Therapy. Guideline of the DGGG, OEGGG and SGGG (S2k, AWMF Registry No. 015-063, August 2022)

Abstract

Aim This official guideline was coordinated and published by the German Society of Gynaecology and Obstetrics (DGGG). The guideline aims to provide a consensus-based overview of the diagnosis and management of peripartum bleeding based on an evaluation of the relevant literature.

Methods This S2k-guideline was developed by representative members from different medical professions on behalf of the guidelines commission of the DGGG, OEGGG and SGGG using a structured consensus process.

Recommendations Recommendations for the definition, risk stratification, prevention, treatment (general emergency procedures, medications, uterine tamponade, surgical measures, interventional-radiological procedures, haemostasis, and coagulation management), transportation, documentation and debriefing as well as training are presented. In addition, a PPH algorithm for action, “PPH 2022”, is recommended.

Key words

postpartum haemorrhage - postpartum bleeding - placenta accreta spectrum - PPH algorithm - uterotonic drugs - tranexamic acid - tamponade - surgical procedures - compression sutures - embolization - haemostasis and coagulation management - anaesthetic management - autotransfusion

I  Guideline Information

Guidelines programme of the DGGG, OEGGG and SGGG

For information on the guidelines programme, please refer to the end of the guideline.

Citation format

Peripartum Haemorrhage, Diagnosis and Therapy. Guideline of the DGGG, OEGGG and SGGG (S2k, AWMF Registry No. 015-063, August 2022). Geburtsh Frauenheilk 2023. doi:10.1055/a-2073- 9615

Guideline documents

The complete long version of this guideline in German together with a list of the conflicts of interest of all of the authors is available on the homepage of the AWMF: http://www.awmf.org/leitlinien/detail/ll/015-063.html

Guideline authors

See [Tables 1] and [2].

Tab. 1 Lead and/or coordinating guideline author.

Author	Professional society
PD Dr. med. Dietmar Schlembach	German Society for Gynaecology and Obstetrics [Dt. Gesellschaft für Gynäkologie und Geburtshilfe e. V.] (DGGG) German Society for Prenatal and Obstetric Medicine [Dt. Gesellschaft für Pränatal- und Geburtsmedizin e. V.] (DGPGM)

Tab. 2 Contributing guideline authors (in alphabetical order, only primary mandate holders).

Author	DGGG working group (AG)/ AWMF/non-AWMF professional society/ organisation/association
Prof. Dr. med. Thorsten Annecke	German Society of Anaesthesiology and Intensive Care Medicine [Dt. Gesellschaft für Anästhesiologie und Intensivmedizin e. V.] (DGAI) German Interdisciplinary Association of Intensive Care and Emergency Medicine [Dt. Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin e. V.] (DIVI)
Prof. Dr. Thierry Girard	Swiss Society for Anaesthesiology and Perioperative Medicine [Schweizerische Gesellschaft für Anästhesie und Perioperative Medizin] (SSAPM)
Univ. Prof. Dr. med. univ. Hanns Helmer	Austrian Society for Gynaecology and Obstetrics [Österreichische Gesellschaft für Gynäkologie und Geburtshilfe] (OEGGG)
Prof. Dr. med. Christian von Heymann	German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
Prof. Dr. med. Franz Kainer	German Society for Perinatal Medicine [Dt. Gesellschaft für Perinatale Medizin e. V.] (DGPM) German Interdisciplinary Association of Intensive Care and Emergency Medicine (DIVI)
Prof. Dr. med. Sven Kehl	German Society of Ultrasound in Medicine [Dt. Gesellschaft für Ultraschall in der Medizin e. V.] (DEGUM)
Prof. Dr. med. Wolfgang Korte	Society for Thrombosis and Haemostasis Research [Gesellschaft für Thrombose- und Hämostaseforschung e. V.] (GTH)
Prof. Dr. med. Maritta Kühnert	Working Group for Obstetrics and Prenatal Medicine [Arbeitsgemeinschaft für Geburtshilfe und Pränatalmedizin e. V.] (AGG) in the German Society for Gynaecology and Obstetrics (DGGG)
Dr. med. Heiko Lier	German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
Silke Mader	European Foundation for the Care of Newborn Infants (EFCNI)
Prof. Dr. med. Andreas Mahnken	German Society for Interventional Radiology and Minimally Invasive Therapy [Dt. Gesellschaft für Interventionelle Radiologie und minimal invasive Therapie e. V.] (DeGIR)
Hon.-Prof. Dr. med. habil. Holger Maul	Professional Association of Gynaecologists [Berufsverband der Frauenärzte e. V.] (BVF) Working Group for Obstetrics and Prenatal Medicine (AGG) in the German Society for Gynaecology and Obstetrics (DGGG)
Dr. med. univ. Georg Pfanner	Austrian Society for Anaesthesiology, Reanimation and Intensive Medicine [Österreichische Gesellschaft für Anästhesiologie, Reanimation und Intensivmedizin] (ÖGARI)
Andrea Ramsell	German Midwives Association [Dt. Hebammenverband e. V.] (DHV)
PD Dr. med. Dietmar Schlembach	Working Group for Obstetrics and Prenatal Medicine (AGG) in the German Society for Gynaecology and Obstetrics (DGGG) German Society for Prenatal and Obstetric Medicine (DGPGM)
Prof. Dr. med. Daniel Surbek	Swiss Society for Gynaecology and Obstetrics [Schweizer Gesellschaft für Gynäkologie und Geburtshilfe] (SGGG)
Dr. med. Oliver Tiebel	German Society for Clinical Chemistry and Laboratory Medicine [Dt. Gesellschaft für Klinische Chemie und Laboratoriumsmedizin e. V.] (DGKL)
Laura Zinßer	German Midwifery Society [Dt. Gesellschaft für Hebammenwissenschaft e. V.] (DGHWI)

The following professional societies/working groups/organisations/associations stated that they wished to contribute to the guideline text and participate in the consensus conference and nominated representatives to attend the conference:

II  Guideline Application

Purpose and objectives

• Presentation of an interdisciplinary algorithm for action and for the management of peripartum haemorrhage (diagnosis, risk selection, treatment)

• To create the algorithm, the existing S2k-guideline had to be revised and updated.

• The aim of revising the guideline was to update the knowledge of all persons caring for pregnant women and women in the postpartum period suffering from or with a higher risk of haemorrhage.

• This should lead to a better care of these patients and reduce problems when managing PPH.

Targeted areas of care

• Outpatient and in-patient care

• Prevention

• Screening, diagnosis, management and therapy

• Medical/specialist care

Targeted patient groups

This guideline is aimed at pregnant women/women giving birth/women in the postpartum period.

Target user groups/target audience

This guideline is aimed at the following groups of people:

• gynaecologists (diagnostic examinations, outpatient care, treatment, prevention, screening)

• anaesthetists, specialists for internal medicine, haemostasis specialists, clinical pathologists

• midwives

and provides information for nursing staff (in the operating room and the postnatal ward).

Adoption and period of validity

The validity of this guideline was confirmed by the executive boards/representatives of the participating medical professional societies, working groups, organizations, and associations and the board of the DGGG and the DGGG Guidelines Commission as well as by the boards of the SGGG and OEGGG in July 2022 and was thereby approved in its entirety. This guideline is valid from 1 August 2022 through to 31 July 2027. Because of the contents of this guideline, this period of validity is only an estimate.

III  Methodology

Basic principles

The method used to prepare this guideline was determined by the class to which this guideline was assigned. The AWMF Guidance Manual (version 2.0) has set out the respective rules and requirements for different classes of guidelines. Guidelines are differentiated into lowest (S1), intermediate (S2), and highest (S3) class. The lowest class is defined as consisting of a set of recommendations for action compiled by a non-representative group of experts. In 2004, the S2 class was divided into two subclasses: a systematic evidence-based subclass (S2e) and a structural consensus-based subclass (S2k). The highest S3 class combines both approaches.

This guideline was classified as: S2k.

Grading of recommendations

The grading of evidence based on the systematic search, selection, evaluation, and synthesis of an evidence base which is then used to grade the recommendations is not envisaged for S2k guidelines. The individual statements and recommendations are only differentiated by syntax, not by symbols ([Table 3]).

Tab. 3 Grading of recommendations.

Description of binding character	Expression
Strong recommendation, highly binding	must/must not
Regular recommendation, moderately binding	should/should not
Open recommendation, not binding	may/may not

Statements

Expositions or explanations of specific facts, circumstances, or problems without any direct recommendations for action included in this guideline are referred to as “statements.” It is not possible to provide any information about the level of evidence for these statements.

Achieving consensus and level of consensus

At structured NIH-type consensus-based conferences (S2k/S3 level), authorised participants attending the session vote on draft statements and recommendations. The process is as follows. A recommendation is presented, its contents are discussed, proposed changes are put forward, and all proposed changes are voted on. If a consensus (> 75% of votes) is not achieved, there is another round of discussions, followed by a repeat vote. Finally, the extent of consensus is determined, based on the number of participants ([Table 4]).

Tab. 4 Level of consensus based on extent of agreement.

Symbol	Level of consensus	Extent of agreement in percent
+++	Strong consensus	> 95% of participants agree
++	Consensus	> 75 – 95% of participants agree
+	Majority agreement	> 50 – 75% of participants agree
–	No consensus	< 51% of participants agree

Expert consensus

As the term already indicates, this refers to consensus decisions taken relating specifically to recommendations/statements issued without a prior systematic search of the literature (S2k) or where evidence is lacking (S2e/S3). The term “expert consensus” (EC) used here is synonymous with terms used in other guidelines such as “good clinical practice” (GCP) or “clinical consensus point” (CCP). The strength of the recommendation is graded as previously described in the chapter Grading of recommendations but without the use of symbols; it is only expressed semantically (“must”/“must not” or “should”/“should not” or “may”/“may not”).

IV  Guideline

1  Background

The reported incidence of postpartum haemorrhage (PPH) is 1 – 3% of all deliveries. Prospective studies have reported that quantitative measurement of blood loss resulted in a PPH rate of around 10% [1], [2], [3], [4]. The incidence of postpartum haemorrhage (PPH) is constantly increasing, mainly due to the rise in cases with uterine atony and placental implantation disorders as well as rising rates of operative vaginal and caesarean section deliveries leading to higher primary blood loss and, in cases delivered by caesarean section, higher PPH rates in subsequent pregnancies [5], [6], [7], [8], [9], [10], [11].

Life-threatening PPH affects around ca. 2/1000 deliveries in the West, with a reported rate of severe maternal morbidity of around 3/1000 deliveries [12], [13], [14], [15], [16], [17]. This makes PPH the cause of around 30% of all maternal deaths in low and middle-income countries and 13% of maternal deaths in industrialised countries [16]. Most maternal deaths from PPH are avoidable, and in 60 – 80% of all cases they are the result of major substandard care [16], [18] – [21]. It is especially important to be aware that the extent of bleeding will be underestimated by 30 – 50% if assessed visually [22] – [25].

The “4 Tʼs” is an English mnemonic used to summarise the causes of PPH (combinations of all four causes are the norm) ([Table 5]) [26]:

Tab. 5 The 4 Tʼs: causes of PPH [26].

Cause	Potential trigger
Tone (focal or diffuse uterine atony – responsible for at least 80% of PPHs [2])	Idiopathic atony Uterine overdistension (from multiparity, hydramnios, fetal macrosomia) Tocolytics Precipitate or delayed delivery/prolonged labour Oxytocin tachyphylaxis (after prolonged administration of oxytocin) Chorioamnionitis Uterine fibroids
Tissue (placenta)	Retained placenta Placenta accreta spectrum (morbidly adherent placenta, placenta accreta/increta/percreta) Placental remnants
Trauma	Vulvovaginal injuries Cervical tears Uterine tear from surgical extension of uterotomy Episiotomy/perineal tear Uterine rupture Uterine inversion
Thrombin (coagulopathy)	Pregnancy-induced: Disseminated intravascular coagulation (DIC) (e.g., with preeclampsia, HELLP syndrome, intrauterine fetal death [IUFD], placental abruption, amniotic fluid embolism) Other: occurs in the context of a PPH: factor deficiencies (loss, consumption, dilution) pre-existing: von Willebrand-Jürgens syndrome, plasmatic coagulation disorders, thrombopathies, coagulopathies

• Tone (postpartum uterine atony),

• Trauma (injury of the birth canal),

• Tissue (retained placental tissue or detachment disorders),

• Thrombin (coagulation decompensation, coagulopathy).

2  Definition

Consensus-based recommendation 2.E1
Expert consensus	Level of consensus +++
The following definition of PPH is recommended: Blood loss of ≥ 500 ml after vaginal delivery Blood loss of ≥ 1000 ml after caesarean section Irrespective of the visible blood loss, PPH must be assumed if the patient presents with clinical signs of haemorrhagic shock (shock index [HF/RRsys] > 0.9).

Clinically, a blood loss of between 500 and 1500 is usually tolerated without symptoms of shock [27], [28]. Symptoms such as agitation, clouding of consciousness, cold sweat, paleness, tachycardia, hypotension, hyperventilation, and oliguria are already signs of severe haemorrhagic shock (shock index [HF/RR_sys] > 0.9) [29], [30].

PPH is categorised into primary and secondary PPH, according to the time when it occurs [26]:

Primary (acute) bleeding:

• usually occurs just a few hours postpartum (often already in the delivery room or operating room).

• The cause is usually atony (> 80%) or trauma resulting in blood loss (e.g., occult intraabdominal or retroperitoneal bleeding).

• Clinically this leads to haemodynamic derangement with a rapid decrease in blood pressure (hypovolaemia).

Secondary (subacute) bleeding/late postpartum bleeding:

• Incidence: occurs in around 0.2 to 2.5% of postpartum women

• Postpartum women often only start bleeding in the postpartum ward or at home.

• Causes of this “secondary” PPH are usually placental remnants, subinvolution of the uterus or infection.

• Clinically, this leads to haemodynamic derangement with tachycardia with a rapid decrease in blood pressure (hypovolaemic-haemorrhagic shock).

3  Risk stratification and prevention

Consensus-based recommendation 3.E1
Expert consensus	Level of consensus +++
Reference: [31]
On ultrasound scans performed in the 1st and 2nd trimester of pregnancy in high-risk cases (e.g., status post repeated caesarean section), the location and structure of the placenta may provide hints of a disorder of placentation. In cases with low lying placenta in the 2nd trimester presence of placenta praevia and/or vasa praevia should be ruled out and documented, if necessary by performing additional ultrasound examinations.

Consensus-based recommendation 3.E2
Expert consensus	Level of consensus +++
Especially in women with a history of risk factors (previous surgeries, esp. previous caesarean section and transmural myomectomy) or clinical findings such as placenta praevia, the presence of PAS should be considered. Further diagnostic ultrasound examinations may aid in the diagnostic work-up.

A detailed medical history, diagnostic ultrasound examinations during prenatal care, estimation of the risk of bleeding, counselling and delivery planing in an appropriate maternity hospital, and timely preparations for an increased loss of blood may reduce the risk of PPH and its consequences for maternal morbidity and mortality [32].

The main risk management problems for PPH are [33], [34], [35], [36]:

• delayed diagnosis and/or therapy due to underestimation of the actual loss of blood,

• delay in providing blood and coagulation products,

• lack of or non-compliance with simple instructions,

• lack of adequate training and further training,

• inadequate or ineffective communication within the interdisciplinary team,

• deficits in the organisational structure,

• delay in implementing and realising treatment standards.

3.1  Risk factors for PPH

A number of risk factors for PPH have been identified. Risk factors can be categorized into sociodemographic and obstetric (based on previous history and current) risk factors ([Table 6]).

Tab. 6 Risk factors for PPH ([26] modified from [37]).

Blood loss	OR or range
	> 500 ml	> 1000 ml
Sociodemographic risk factors
Obesity (BMI > 35)	1.6
Maternal age (≥ 30 years)	1.3 – 1.4	1.6
Obstetric risk factors
Placenta praevia	4 – 13.1	15.9
Premature placental detachment	2.9 – 12.6	2.6
Retained placenta	4.1 – 7.8	11.7 – 16.0
Prolonged placental stage	7.6
Preeclampsia	5.0
Multiple pregnancy	2.3 – 4.5	2.6
Status post PPH	3.0 – 3.6
Fetal macrosomia	1.9 – 2.4
HELLP syndrome	1.9
Hydramnios	1.9
(Prolonged) oxytocin augmentation	1.8
Induction of labour	1.3 – 2	2.1 – 2.4
Protracted labour	1.1 – 2
Fibroids
Uterine malformations
Grand multiparity
Surgical risk factors
Emergency caesarean section	3.6
Elective caesarean section	2.5
Operative vaginal birth	1.8 – 1.9
Episiotomy	1.7 – 2.21	2.07
Perineal tear	1.7	2.5
Other risk factors
Antepartum bleeding	3.8
Von Willebrand syndrome (esp. types 2 and 3)	3.3
Anaemia (< 9 g/dl)	2.2

3.2  Risk stratification

A general risk stratification to predict PPH (e.g., using a score) does not currently exist and is not recommended for use in practice.

Known risk factors – particularly those associated with a high relative risk of PPH – must be considered on a case-by-case basis when taking the relevant preventive (e.g., organisational) steps [26].

Recent reports have confirmed the purpose and benefit of standardised treatment algorithms and their review during regular audits [32], [38], [39]. An interdisciplinary (anaesthesiology and intensive care medicine, obstetrics) algorithm, known as the PPH 2022 algorithm, has been developed as a transnational algorithm for Germany, Austria, and Switzerland ([Fig. 1]) [26].

Fig. 1 Interdisciplinary algorithm (“PPH 2022”) for the management of PPH, based on: PPH Guideline 2022 AWMF Registry No. 015/063 of the BVF, DGGG (AGG), DeGIR, DEGUM, DGAI, DGHWI, DGKL, DGPM, DGPGM, DHV, DIVI, EFCNI (Pat.), GTH, OEGARI, OEGGG, SGGG, SSAPM (listed alphabetically) [26]. [rerif]

3.3  Placental detachment disorders: placenta praevia/placenta accreta spectrum (PAS)

3.3.1  Placenta praevia

Consensus-based statement 3.S1
Expert consensus	Level of consensus +++
References: [40], [41], [42], [43], [44]
A previous caesarean section is associated with a higher risk of placenta praevia in subsequent pregnancies. The risk increases with the number of deliveries by caesarean section. The risk of placenta praevia is also higher following curettage (e.g., termination of pregnancy, miscarriage) or multiple pregnancies.

Consensus-based statement 3.S2
Expert consensus	Level of consensus +++
References: [45], [46], [47], [48]
In vitro fertilisation (IVF) procedures increase the risk of placenta praevia.

Consensus-based statement 3.S3
Expert consensus	Level of consensus +++
Reference: [48]
Nicotine abuse increases the risk of placenta praevia.

3.3.1.1  Diagnosing placenta praevia

Consensus-based recommendation 3.E3
Expert consensus	Level of consensus +++
References: [31], [49]
Ultrasound examination in the 2nd trimester of pregnancy must determine and record the location, structure and umbilical cord insertion site of the placenta. If ultrasound examination shows a low-lying placenta, placenta praevia should be excluded and the patient should be investigated for vasa praevia, if necessary, by performing another ultrasound examination; ultrasound findings should be documented.

Consensus-based recommendation 3.E4
Expert consensus	Level of consensus +++
Reference: [50]
If ultrasound examination in the 2nd trimester of pregnancy shows a low-lying placenta (≤ 20 mm distant from the internal cervical os) or placenta praevia, another assessment of the placental location must be carried out to confirm the diagnosis at 28 + 0 weeks of gestation and, if necessary, at 32 + 0 weeks of gestation.

Consensus-based recommendation 3.E5
Expert consensus	Level of consensus +++
References: [50], [51]
Transvaginal ultrasound assessment must be carried out if there is a suspicion of placenta praevia, vasa praevia or placenta accreta spectrum.

Consensus-based statement 3.S4
Expert consensus	Level of consensus +++
Reference: [50]
Transvaginal ultrasound is the gold standard to diagnose placenta praevia (sensitivity 87.5%, specificity 98.8%, PPV 93.3%, NPV 97.6%).

Consensus-based recommendation 3.E6
Expert consensus	Level of consensus +++
References: [50], [52], [53], [54], [55]
In cases with placenta praevia, measurement of cervical length may be used to plan further management in asymptomatic pregnant women. A short cervix before 34 + 0 weeks of gestation increases the risk of emergency C-section and massive PPH. In principle, if placenta praevia totalis has been confirmed, inpatient admission should be considered from week 24 + 0 of gestation.

3.3.2  Placenta accreta spectrum (PAS)

Disorders of placental implantation are currently grouped together under the term PAS (placenta accreta spectrum).

Consensus-based statement 3.S5
Expert consensus	Level of consensus +++
References: [43], [50], [56], [57], [58]
The main risk factors for PAS are disorders of placental implantation in a previous pregnancy, previous caesarean section, and other uterine surgeries (e.g., transmural myomectomy). The risk increases with the number of previous caesarean sections. Placenta praevia is an independent risk factor for PAS.

Consensus-based recommendation 3.E7
Expert consensus	Level of consensus +++
References: [18], [59]
In principle, pregnant women with suspected disorders of placentation must present early to a maternity hospital with a suitable organisational structure where, if the suspicion is confirmed, the patient should be treated by an experienced multidisciplinary team (“at the optimum time by the best team”).

3.3.2.1  Diagnosing placenta accreta spectrum

Consensus-based statement 3.S6
Expert consensus	Level of consensus +++
Reference: [50]
If PAS is suspected antenatally, taking the appropriate steps will reduce maternal morbidity and mortality.

Population studies have shown that PAS was not recognised prenatally in 50 – 66% of cases [57], [60]; even specialised centres do not detect around ⅓ of cases prenatally [61].

Consensus-based recommendation 3.E8
Expert consensus	Level of consensus +++
Reference: [26]
Implantation disorders (placenta accreta spectrum) must be considered, especially if the patientʼs medical history indicate that she has a high risk of PAS (previous surgeries) or examination findings (placenta praevia) show that the patient is at high risk.

3.3.2.1.1  (Doppler) sonography

Consensus-based recommendation 3.E9
Expert consensus	Level of consensus +++
Reference: [26]
A detailed ultrasound examination must be carried out if PAS is suspected. Additional MRI may be considered in cases where the findings are unclear.

Consensus-based statement 3.S7
Expert consensus	Level of consensus +++
References: [62], [63], [64]
As the majority of PAS are a consequence of low-lying implantation of the placenta in the area of the caesarean section scar, transvaginal ultrasound examination in the 1st and 2nd trimester of pregnancy may contribute to early (suspected) diagnosis and direct the further management of the patient.

Sonographic signs of PAS include the following (not all of which must always be detectable) ([Table 7]).

Tab. 7 (Doppler) ultrasound signs of PAS (modified from [50], [65]).

Ultrasound findings	Description
B-mode image
Loss of clear zone	Loss or irregularity of the hypoechoic retroplacental clear zone in the myometrium beneath the placental bed
“Moth-eaten” lacunae	Image shows numerous irregular (“moth-eaten”) lacunae, some of which show turbulent flow in B-mode, typically perpendicular at the uterovesical interface
Bladder wall interruption	Loss or irregularity of the hyperechoic layer of the bladder wall
Myometrial thinning	Thinning (< 1 mm) or loss of myometrium in the area of the placenta
Placental bulge	Outpouching of the uterine serosa from the expected plane, caused by abnormal placental tissue, although the serosa appears intact
Focal exophytic placental tissue	Placental tissue breaks through the uterine serosa (e.g., into the bladder)
Doppler sonography
Uterovesical hypervascularity	Increased imaging of irregular vascular perfusion between the myometrium and the posterior wall of the bladder (numerous spiral vessels with bidirectional flow)
Subplacental hypervascularity	Increased imaging of irregular vascular perfusion in the placental bed (numerous spiral vessels with bidirectional flow)
Bridging vessels	Imaging of vessels which extend from the placenta through the myometrium and serosa into the bladder or other organs – often perpendicular to the myometrium
Afferent vessels to the placental lacunae	Vessels with high velocity of blood flow from the myometrium to the lacunae
3-D Doppler sonography
Intraplacental hypervascularity (power Doppler)	Complex irregular placental vessels with tortuous courses

3.3.2.1.2  Magnetic resonanc imaging (MRI)

Consensus-based statement 3.S8
Expert consensus	Level of consensus +++
Reference: [26]
MRI examinations are not routinely carried out to diagnose PAS but may offer additional information in cases where findings are inconclusive.

Consensus-based recommendation 3.E10
Expert consensus	Level of consensus +++
References: [66], [67], [68]
Contrast media (gadolinium) must not be routinely used to diagnose PAS.

3.3.2.1.3  Biomarkers

Consensus-based recommendation 3.E11
Expert consensus	Level of consensus +++
References: [26], [69], [70]
Biomarkers must only be used during diagnostic investigations for PAS in the context of registered clinical studies.

4  Prevention of PPH

4.1  Prevention of PPH during vaginal delivery

4.1.1  Active management of the third stage of labour in vaginal deliveries

Consensus-based recommendation 4.E1
Expert consensus	Level of consensus ++
References: [71], [72], [73], [74]
Active management of third stage of labour (AMTSL) reduces the risk of PPH by up to 66% and must therefore be recommended for every delivery.

The most decisive step consists of the prophylactic administration of uterotonic drugs [75], [76]; basically, it is important to ensure the following [26]:

• provide antenatal information about management in the third stage of labour and take the wishes of the pregnant woman into consideration (consent).

• it is important to allow the mother (and her birth companion) and the neonate to get to know each other (bonding); this promotes the endogenous release of oxytocin and should be facilitated so that they can be undisturbed – as long as the situation permits – during the first hour together.

Consensus-based recommendation 4.E2
Expert consensus	Level of consensus +++
Reference: [26]
During vaginal delivery, early clamping and cutting of the umbilical cord immediately after the delivery of the neonate accompanied by controlled traction on the umbilical cord does not reduce postpartum haemorrhage and should not be carried out.

4.1.2  Medication prophylaxis against PPH

4.1.2.1  Uterotonic drugs

Consensus-based recommendation 4.E3
Expert consensus	Level of consensus +++
Reference: [26]
Oxytocin 3 – 5 IU IV or carbetocin 100 µg IV (both administered by short infusion) may be used for medication prophylaxis against PPH or administered IM in cases of vaginal delivery; carbetocin is effective for longer and has the same side-effects rate.

4.1.2.1.1  Oxytocin/carbetocin

When oxytocin or carbetocin are administered IV, it is important to remember that a quick (bolus) injection will lead to a decrease in blood pressure with reflex tachycardia [77], [78]. That is why these agents should be administered by short infusion; a slow IV injection may be necessary. Alternatively, both oxytocin and carbetocin may be administered IM.

4.1.2.1.2  Methylergometrine

Consensus-based recommendation 4.E4
Expert consensus	Level of consensus +++
References: [79], [80]
Methylergometrine has more side effects than oxytocin and carbetocin, and should therefore not be administered as a first choice medication.

4.1.2.1.3  Misoprostol

Consensus-based recommendation 4.E5
Expert consensus	Level of consensus +++
References: [26]
Misoprostol is less effective than oxytocin and carbetocin and should therefore not be administered as a first choice medication.

4.1.2.1.4  Antifibrinolytic agents

Consensus-based recommendation 4.E6
Expert consensus	Level of consensus +++
References: [81], [82]
Tranexamic acid must not be routinely used for bleeding prophylaxis but only therapeutically following a diagnosis of PPH.

4.2  Prevention of PPH during caesarean section

Consensus-based recommendation 4.E7
Expert consensus	Level of consensus +++
References: [26], [83], [84], [85]
Similar to vaginal deliveries, medication must be administered as a prophylaxis against PPH in every caesarean section delivery. As with vaginal births, oxytocin 3 – 5 IU IV or carbetocin 100 µg IV may be administered (both by short infusion); carbetocin is effective for a longer period and has the same side-effects rate.

4.3  Prevention when risk factors are present

Consensus-based recommendation 4.E8
Expert consensus	Level of consensus +++
Reference: [26]
In hospital, the following measures must be implemented before inducing labour if the patient has known risk factors: obstetrician and anaesthesiologist must both be in-house and have been informed; an experienced obstetrician and experienced anaesthesiologist must be on call placement of adequate intravenous access during delivery in every woman giving birth; large-lumen venous access points may be placed for bleeding complications provision of uterotonic drugs: oxytocin, carbetocin, sulprostone Check logistics: provision of antifibrinolytic agents (tranexamic acid) urgent laboratory tests can be carried out (blood count, arterial blood gas analysis [ABG], aPTT, Quick or INR and, if available, fibrinogen, factor XIII, viscoelastic test [VET]) blood bank/blood depot: crossmatch test; red cell concentrates, fresh frozen plasma and platelet concentrates available in good time Availability of coagulation factors, fibrinogen, factor XIII, recombinant Factor VIIa (rFVIIa).

5  General (emergency) measures and diagnostic steps to determine causes

5.1  Estimating the severity of bleeding

Consensus-based statement 5.S1
Expert consensus	Level of consensus ++
References: [26], [32], [86], [87], [88], [89]
Visual estimates of blood loss are inaccurate. Validated measurement methods to determine the extent of blood loss should be preferred.

Consensus-based recommendation 5.E1
Expert consensus	Level of consensus +++
Reference: [26]
All underlays, pads, linen “soaked” with blood and all coagula must be collected and weighed if the bleeding increases/in cases with PPH.

Consensus-based recommendation 5.E2
Expert consensus	Level of consensus +++
References: [29], [30]
The patientʼs clinical symptoms (signs of hypovolaemia) must be considered when estimating the extent of blood loss: shock index (HF/RRsys) > 0.9.

Consensus-based recommendation 5.E3
Expert consensus	Level of consensus +++
Reference: [26]
When caring for a bleeding patient, Hb values must be checked in good time and regularly; it is important to be aware that Hb levels will be slow to respond and cannot replace gravimetric measurements. Early signs of critical hypovolaemia may include reduced base excess (BE) levels in venous blood gas analysis and elevated lactate levels. Alarming signs: BE < −6 mmol/l and lactate > 4 mmol/l.

5.2  Communication and multidisciplinary teams

Consensus-based statement 5.S2
Expert consensus	Level of consensus ++
Reference: [26]
From the start, the woman giving birth/postpartum woman and her companion(s) must be informed about the bleeding and the approach taken in words that can be understood by laypersons.

Consensus-based recommendation 5.E4
Expert consensus	Level of consensus +++
Reference: [26]
Depending on the situation/the loss of blood, experienced midwives and obstetricians as well as the anaesthesiologist and other medical specialists must be informed and consulted (see PPH algorithm, [Fig. 1]).

5.3  General measures against PPH

Consensus-based statement 5.S3
Expert consensus	Level of consensus +++
References: [26], [90], [91]
In addition to general measures (for haemodynamic stabilisation or uterine compression → Hamilton procedure), treatment of PPH consists of the appropriate drug therapy and/or surgical and/or interventional therapy which must be quick, coordinated, and often performed simultaneously (see PPH algorithm, [Fig. 1]).

6  Pharmaceutical therapy to treat PPH

6.1  Uterotonic drugs

6.1.1  Oxytocin IV (poss. IM)

Consensus-based recommendation 6.E1
Expert consensus	Level of consensus +++
References: [26], [92], [93], [94]
Oxytocin must be used as first-line therapy for primary PPH. Compared to misoprostol, oxytocin is more effective, particularly after vaginal birth, and has fewer side effects. Overall, a maximum of 6 – 10 IU may be administered as a short infusion: 3 – 5 IU by short infusion followed by 10 – 40 IU oxytocin in 500 – 1000 ml as a continuous intravenous drip (dose depends on effect on the uterus)

The onset of effect following IV administration occurs (with a half-life period of around 10 min outside pregnancy and 3 – 4 min in pregnant women) within one minute; following intramuscular administration, (a maximum of 10 IU) it occurs within 3 – 5 minutes [95].

6.1.2  Carbetocin

The therapeutic use of carbetocin to treat PPH is an off-label use, as it has currently not yet been sufficiently validated in studies. The administration of carbetocin to treat PPH has been reported in individual cases.

6.1.3  Methylergometrine

Consensus-based recommendation 6.E3
Expert consensus	Level of consensus +++
Reference: [26]
Because of its range of side effects, methylergometrine should not be used to manage postpartum bleeding as other alternatives are available in Europe.

6.1.4  Prostaglandins

Consensus-based recommendation 6.E4
Expert consensus	Level of consensus +++
References: [26], [96], [97], [98]
If first-line uterotonic drugs fail or the patient does not respond, medication must be switched without delay to prostaglandins. The use of sulprostone is recommended because of its favourable efficacy profile and relatively limited side effects.

Consensus-based recommendation 6.E5
Expert consensus	Level of consensus +++
References: [26], [99]
Oxytocin receptor agonists and prostaglandins should not be administered at the same time. If a rapid transition from oxytocin receptor agonists to sulprostone is necessary for clinical reasons, the cardiovascular side effects should be carefully monitored.

If first-line uterotonic drugs fail or the patient does not respond to them, medication must be switched to prostaglandins without delay; it is not necessary to observe a time gap/pause (particularly when administering carbetocin) between medications.

6.1.4.1  Sulprostone

Consensus-based recommendation 6.E6
Expert consensus	Level of consensus +++
Reference: [26]
Sulprostone must be exclusively administered intravenously (infusion pump/syringe driver). Because it is difficult to control, intramuscular or intramyometrial administration must be avoided.

The following de-escalating regimen to administer sulprostone has been found to be useful for the clinical management of PPH (recommendation of the guideline authors):

• dosage 500 µg in 500 ml carrier fluid (via an infusion pump)

• de-escalating run time, i.e.

  • 3 min at 500 ml/h or 8.3 ml/min (8.3 µg/min), then

  • 7 min at 100 ml/h or 1.7 ml/min (1.7 µg/min),

  • followed by 10 – 20 ml/h or 0.2 – 0.4 ml/min

• max. 1500 µg/d

6.1.4.2  Misoprostol

Consensus-based statement 6.S1
Expert consensus	Level of consensus +++
Reference: [26]
Because of its delayed onset of action and the availability of better approved alternatives, misoprostol is not suitable for the treatment of persistent PPH.

The use of misoprostol may be considered (off-label use!) to treat moderately persistent PPH after administering oxytocin; however, the current data are not sufficient to permit a final recommendation to be made.

6.1.4.3  Intrauterine administration of prostaglandins

Consensus-based recommendation 6.E7
Expert consensus	Level of consensus +++
References: [26], [97]
Sulprostone must not be administered by intramyometrial or intracervical application.

6.2  Antifibrinolytic drugs (tranexamic acid)

Consensus-based recommendation 6.E2
Expert consensus	Level of consensus +++
References: [100], [101], [102]
After PPH is diagnosed, tranexamic acid 1 g IV must be administered at the same time as oxytocin receptor agonists are administered, without a prior coagulation analysis. The earlier tranexamic acid is administered, the more effective it will be.

7  Uterine tamponade

In addition to other second-line treatment strategies, uterine tamponade may significantly reduce the rate of emergency hysterectomies [103], [104], [105].

Different balloon systems (approved systems: Bakri balloon, ebb Complete Tamponade System) are available for uterine tamponade, in addition to tamponade strips. Their efficacy has been confirmed in different publications and they offer the advantage that persistent bleeding is recognised early [105], [106], [107], [108], [109], [110], [111], [112], [113], [114], [115].

There have been several recent case series reporting on the use of gauze (Celox) coated with a haemostatic agent (chitosan), originally developed for emergency and military medicine, as an intrauterine tamponade to manage PPH. The use of this type of gauze should be preferred to a simple gauze tamponade, especially for anticoagulation [116] – [118]. In November 2022, the manufacturer reported that Celox PPH, a special variant of Celox, was CE certified.

In recent years, more reports on the use of uterine packing, i.e., uterine tamponade with gauze have been published [105], [107], [119]. Potential drawbacks include possible occult bleeding as well as bleeding on removal and, potentially, pain when removing the tamponade.

Vacuum-induced uterine tamponade is a method which has not yet been widely used in German-speaking countries [120] – [126].

A combination of different tamponade methods with uterine compression sutures, similar to a “sandwich technique,” have been successfully used in different case series [127], [128], [129], [130].

Consensus-based recommendation 7.E1
Expert consensus	Level of consensus +++
References: [106], [112], [127], [131], [132], [133]
Uterine tamponade, irrespective of the chosen method, does not exclude the use of other potentially necessary therapeutic options such as compression sutures; they are urgently recommended when treating atony.

8  Surgical measures

8.1  Bridging interdisciplinary measures

In the event of the lethal triad of persistent bleeding, haemorrhagic shock and coagulopathy, the recommended approach must be damage control surgery, carried out in three stages [134], [135]:

• Surgical haemostasis carried out within an acceptable time frame using a Pfannenstiel incision or median laparotomy, eventration of the uterus with cranial traction and uterine compression and atraumatic clamping of the uterine arteries to minimise perfusion. Placement of uterine compression sutures and application of a uterine tamponade.

• In parallel, anaesthetic and intensive care measures performed to correct hypovolaemia, hypothermia, acidosis and coagulopathy; if necessary, surgery must be paused until the patient is stable.

• Definitive (surgical) treatment of the now haemodynamically stabilised patient by a surgeon with the appropriate surgical expertise. If the infrastructure is available, one option may be interventional radiological embolization of the afferent uterine arteries [136], [137].

Consensus-based recommendation 8.E1
Expert consensus	Level of consensus +++
References: [135], [138], [139], [140], [141]
Bimanual compression of the aorta for up to 20 minutes may be carried out during the “bridging period” to avoid unnecessary loss of blood. If it is foreseeable that the bleeding cannot be controlled by a hysterectomy or if the bleeding continues despite performing a hysterectomy, packing of the pelvis and abdomen should be carried out using a sufficient number of moistened abdominal bandages. If interventional radiological measures can be carried out, temporary balloon occlusion of the aorta may be performed.

8.2  Compression sutures

Consensus-based recommendation 8.E2
Expert consensus	Level of consensus +++
Reference: [26]
Appropriate suturing materials (large needle, long sutures) must be kept on hand in operating rooms for uterine compression sutures.

In the last 15 years, the range of surgical treatment options has been significantly expanded by the use of uterine compression sutures [142]. This method aims to compress the uterus and reduce the size of the placental adhesion surface, creating a tamponade at the bleeding site.

It is currently not possible to make a statement about the optimal efficacy of any specific method; a suitable suturing technique should be used according to the indication (atony, bleeding from the placental bed, diffuse bleeding) [26], [143].

8.3  Vascular ligations

In addition to simple ligation of the uterine artery, stepwise uterine devascularisation may also be carried out. This technique consists of five consecutive steps to ligate the ascending and descending branches of the uterine arteries and collateral branches of the ovarian artery [144], [145].

Consensus-based recommendation 8.E3
Expert consensus	Level of consensus +++
Reference: [26]
Ligation of the internal iliac artery must only be carried out as an ultima ratio and only by a surgeon with extensive experience of pelvic surgery.

8.4  Postpartum hysterectomy

Consensus-based recommendation 8.E4
Expert consensus	Level of consensus +++
References: [26], [146], [147]
Conservative measures to preserve the uterus are only reasonable as long as the patient is haemodynamically stable and bleeding is not life-threatening. If a hysterectomy is necessary, the decision should not be delayed.

Consensus-based recommendation 8.E5
Expert consensus	Level of consensus +++
Reference: [26]
Supracervical hysterectomy should be preferred in cases with atony as the operating time is significantly shorter and it does not result in unintended shortening of the vagina. Total hysterectomy may be considered in cases with placental implantation disorders or cases with injuries of the lower uterine segment; imaging of the ureters is recommended in these cases.

Relative contraindications for uterus-preserving measures include:

• extensive placental implantation disorders (placenta increta/percreta) where the placental implantation bed is open, bleeding at the placental implantation bed does not respond to therapy or the placental implantation bed covers large areas of the uterine wall,

• non-reconstructable uterine injury,

• septic uterus.

9  Interventional radiological procedures: transarterial techniques

• temporary/intermittent balloon occlusion of the iliac arteries

• temporary/intermittent balloon occlusion of the aorta

• embolization of the uterine arteries

Consensus-based recommendation 9.E1
Expert consensus	Level of consensus +++
Reference: [26]
Every obstetric department must ascertain which interventional radiological procedures are available to treat PPH. If these procedures can be carried out in-house or locally, an appropriate interdisciplinary treatment pathway should be agreed on, which will include the use of interventional radiological techniques at an early stage after conservative measures have been exhausted.

Consensus-based recommendation 9.E2
Expert consensus	Level of consensus +++
Reference: [26]
If a radiological procedure/treatment is indicated, the radiology department should be informed early on (e.g., if haemostasis is unsuccessful after placing uterine compression sutures).

Consensus-based recommendation 9.E3
Expert consensus	Level of consensus ++
Reference: [26]
Other treatment options should be largely exhausted prior to carrying out interventional radiological treatment.

Consensus-based recommendation 9.E4
Expert consensus	Level of consensus +++
Reference: [26]
If the procedure can be planned (e.g., in cases with placenta accreta spectrum), vascular access and placement of the occlusion balloon may already be carried out preoperatively.

10  Haemostasis and coagulation management

10.1  Background

Consensus-based statement 10.S1
Expert consensus	Level of consensus +++
Reference: [26]
The leading causes of PPH are atony, traumatic injury, placental remnants, and coagulation disorders. It is rare for a primary coagulation disorder (coagulopathy) to be the cause of PPH. The coagulopathy is usually acquired during PPH ([Fig. 2]).

Fig. 2 Pathophysiology of obstetric coagulopathy [26]. [rerif]

According to the concept of the 4 Tʼs, atony, placental retention, and vascular lesions accompanied by increased fibrinolytic activity are the most important causes of PPH. If early treatment of the cause is unsuccessful, persistent PPH will always result in a coagulopathy, irrespective of the original cause [148], [149], [150].

The larger the volume of replacement fluids, the worse the coagulation parameters will be [151]. Orientating perioperative levels for haemodynamic stability are BE > −6 mEq/l, lactate < 4 mmol/l and pCO₂ gap < 6 mmHg [152].

Consensus-based recommendation 10.E1
Expert consensus	Level of consensus +++
References: [26], [91], [153], [154], [155], [156]
All hospitals with obstetric departments must develop a treatment algorithm for the peripartum/postpartum period which is adapted to the conditions in the respective hospital. The focus must be on early diagnosis and the targeted treatment of bleeding. The algorithm must define the approach used for treatment and include all available treatment options including pharmacological, haemostatic, radiological interventions, and surgical measures.

10.2  Options to treat peri-/postpartum coagulopathic bleeding

Consensus-based recommendation 10.E2
Expert consensus	Level of consensus +++
Reference: [26]
In cases with active bleeding, iatrogenic aggravation of the tendency to bleed must be avoided, e.g., artificial colloidal volume replacement solutions should be avoided, as they have a strong dilutional and coagulopathic effect.

Consensus-based statement 10.S2
Expert consensus	Level of consensus +++
Reference: [26]
Standard haemostatic therapy to treat severe peripartum bleeding consists of the early administration of tranexamic acid, coagulation factor concentrates and/or fresh frozen plasma with coagulation factors (FFP) to avoid an additional dilutional coagulopathy in addition to the ongoing loss of blood.

Consensus-based recommendation 10.E3
Expert consensus	Level of consensus +++
References: [26], [91]
In cases with persistent bleeding, evidence of a lack of coagulation factors is useful to determine the appropriate targeted therapy. Evidence for coagulation factor deficiencies should be obtained from laboratory parameters (e.g., hemogram, blood gas analysis [BGA], aPTT, Quick or INR and, if available, fibrinogen, factor XIII, and viscoelastic tests [VET]).

In addition to primary haemostasis, recent data have shown that when treating patients with peripartum bleeding, in addition to fibrinogen [37], [91], the focus must also be on other components of the final steps of the coagulation pathway [157], [158]. It is important to ensure a balanced replacement of all components involved in cases with a specifically identified or anticipated deficiency (justifiable targets: FXIII > 60% [157], [158], platelets 70 – 100 Gpt/l [159], fibrinogen > 2 – 2.5 g/l [160], [161], [162]).

Consensus-based recommendation 10.E4
Expert consensus	Level of consensus +++
References: [26], [37], [91]
To begin with, any existing increased fibrinolytic activity must be treated by the administration of tranexamic acid (antifibrinolytic agent) before administering procoagulant factors (platelets, fibrinogen, FXIII, PPSB). For dosage recommendations, see recommendation 10.E6.

Consensus-based recommendation 10.E5
Expert consensus	Level of consensus ++
References: [26], [91], [154], [155], [159], [163], [164], [165], [166], [167], [168], [169] * Note: After the procedure to achieve consensus had been concluded/AWMF guideline 015/063 had been submitted, the official approval for recombinant Factor VIIa (rFVIIa) was expanded to include its use to treat “severe postpartum bleeding when uterotonic drugs are not sufficient to achieve haemostasis”. In this expanded official approval, the use of rFVIIa was proposed for patients who failed to respond to sulprostone, with a proposed rFVIIa dosage of 60 – 90 µg/kg; this should take effect within 10 minutes; a possible second dose may be administered after 30 minutes [170]. Without postponing the publication date of the guideline, the guidelines commission was unable to evaluate all of the published data on the use of rFVIIa in patients with severe PPH who do not respond to uterotonic drugs. The decision was therefore taken not to change the current recommendation regarding the use of rFVIIa as a last resort for patients with severe refractory PPH who do not respond to all other treatment options, and to evaluate the literature on the use of rFVIIa in any subsequent revision of the guideline.
Recommendations for the haemostatic management of persistent PPH requiring substitution are: a treatment concept adapted to the specific conditions in the respective hospital restoring or securing the conditions for coagulation temperature (> 34 °C) calcium (> 0.9 mmol/l) pH (> 7.2) administration of tranexamic acid immediately after diagnosing PPH fresh frozen plasma (FFP) for plasma volume replacement targeted coagulation therapy carried out in parallel to surgical, mechanical and supplementary measures: administration of concentrates: fibrinogen concentrate, FXIII (e.g., blood loss > 50% TBV) and PPSB platelet concentrates rFVIIa (See Note*) For dosage recommendations, see recommendation 10.E6.

There are currently no reliable data which would permit an evidence-based recommendation to be made on the use of DDAVP (desmopressin) in obstetrics as an acute therapy to treat bleeding [171], even though a positive effect has been repeatedly observed [172].

DDAVP must only be administered under the following conditions [26]:

• only for thrombopathies known to respond to DDAVP (consultation with the haemostasiology department recommended!)

• not to patients with known “sub”-haemophilia A (i.e., carriers for haemophilia A)

• not to patients known to have von Willebrand syndrome type 1

• after umbilical cord clamping and cutting

Consensus-based recommendation 10.E6
Expert consensus		Level of consensus ++
Reference: [26]
1	Stabilisation of the patientʼs general condition (prophylaxis and therapy!)	Core temperature ≥ 34 °C (ideally normothermia) pH ≥ 7.2 ionised Ca++ concentration > 0.9 mmol/l (ideally normocalcemia)
2	Inhibition of potential hyper-fibrinolytic activity (always before administering fibrinogen and/or fresh frozen plasma)	Tranexamic acid initially 1 g If needed, one repeat dose
3	Substitution of oxygen carriers	RBC administration haemostatic goal in cases with severe bleeding: Hb ca. 7 – 9 g/dl (4.3 – 5.5 mmol/l)
4	Substitution of coagulation factors (for persistent increased bleeding tendency) depending on availability in the hospital Patients who (will) require massive transfusions or who are suffering from haemorrhagic life-threatening shock may benefit from a high ratio of FFP : RBC : PC, for example, 4 (to 6) to 4 (to 6) to 1, or combined administration of plasma and factor concentrates as well as platelet concentrates	Fibrinogen 30 – 60 mg/kg BW, goal: ≥ 2 – 2.5 g/l and FXIII 20 IU/kg BW, goal: FXIII activity > 60% or FFP ≥ 30 ml/kg BW or PPSB initially 25 IU/kg BW
5	Replace plasma volume	FFP ≥ 30 ml/kg BW
6	Platelet substitution for primary haemostasis	Platelet concentrates (for persistent bleeding requiring transfusion; goal: ≥ 70 – 100 Gpt/l)
7	If necessary, a “thrombin burst” with platelet and coagulation activation (consider haemostatic conditions!)	In individual cases: ggf. rFVIIa initial 60(– 90) µg/kg BW
Caution: no antithrombin or heparin during bleeding thrombosis prophylaxis is mandatory (!) within 24 hours after cessation of the pathology which caused the bleeding possibly DDAVP (desmopressin) 0.3 µg/kg BW for 30 min (in cases with [suspected] acquired thrombocytopenia – only after clamping and cutting)

Consensus-based statement 10.S2
Expert consensus	Level of consensus +++
References: [26], [37], [173]
There is an increased risk of thromboembolism after haemostasis due to reduced antithrombin activity (in some instances, absolute activity < 50%). This necessitates thrombosis prophylaxis within 24 hours; in cases with risk factors, thrombosis prophylaxis should be continued for up to 6 weeks postpartum.

Consensus-based recommendation 10.E7
Expert consensus	Level of consensus +++
References: [174], [175], [176]
Antithrombin activity may be determined in the intensive care unit and substitution may be considered after cessation of bleeding, especially after administering concentrates of individual coagulation factors or complex preparations (especially PPSB).

10.3  Anaesthesia-related aspects of managing PPH

Consensus-based recommendation 10.E8
Expert consensus	Level of consensus +++
Reference: [26]
A timely call for expert assistance should be considered when blood loss is more than 1000 ml and expert assistance must be called in when persistent blood loss is 1500 ml.

Consensus-based recommendation 10.E9
Expert consensus	Level of consensus +++
Reference: [26]
Haemodynamic stability must be maintained or achieved during PPH. Needs-based volume replacement therapy must be carried out with careful monitoring of volumes to avoid iatrogenic over-infusion. The haemodynamic response to the administered fluid volume must be monitored.

Consensus-based recommendation 10.E10
Expert consensus	Level of consensus +++
References: [26], [177]
Secure the airways and ensure a sufficient oxygen supply to patients receiving regional anaesthesia (spinal anaesthesia, epidural anaesthesia): early intubation should be considered for a blood loss of ≥ 1500 ml with signs of persistent bleeding. If there is a loss of protective reflexes, endotracheal intubation to secure the airways and ensure a sufficient oxygen supply must take priority.

Consensus-based recommendation 10.E11
Expert consensus	Level of consensus +++
References: [26], [177], [178], [179], [180]
Large-lumen access points (2 × ≥ 16 G) must be placed; arterial blood pressure measurement should be carried out as a secondary measure, if needed; when in doubt, create a wide-lumen central (≥ 9 Fr) access and use a massive transfusion unit.

Consensus-based recommendation 10.E12
Expert consensus	Level of consensus +++
References: [26], [181]
After cessation of bleeding, intravenous (or oral) iron substitution may be carried out according to local conditions to compensate for the iron deficiency as evidenced by laboratory analysis (soluble transferrin receptor or ferritin < 100 ug/l and transferrin saturation < 20%) or decreased haemoglobin levels (< 9.5 g/dl).

10.3.1  Mechanical autotransfusion (MAT) for PPH

Consensus-based recommendation 10.E13
Expert consensus	Level of consensus +++
Reference: [26]
Mechanical autotransfusion should be considered for patients with increased risk of bleeding.

• National recommendations and international guidelines recommend mechanical autotransfusion for patients with severe PPH (CMACE, NICE, OAA/AAGBI, ESAIC).

• Only after amniotic fluid has been suctioned and the infant has been delivered [182].

• Initially, only “collect” (i.e., create a reservoir); carry out “washing” if needed (i.e., additional suction system with tubing); in such cases, standard use of autotransfusion may also be cost-effective [183], [184].

• Auto-transfused blood contains no coagulation factors or platelets; coagulation factors should be substituted to avoid coagulopathy following high transfusion volumes [185].

• Use of leukocyte depletion filters has been recommended based on theoretical considerations. Recent studies do not consider this to be necessary [183], [184], [186].

• Standard use of autotransfusion in all caesarean section results in re-transfusion volumes of around 250 ml [183], [184]; the use of autotransfusion can therefore only be recommended for patients with a high risk of bleeding.

• We recommend obtaining a guarantee from the respective manufacturer of the device that the unit will wash out tissue-factor-containing amniotic fluid/placental tissue.

10.4  Benefit of diagnostics using a point-of-care (PoC) approach and standard lab tests for coagulation analysis

Consensus-based statement 10.S3
Expert consensus	Level of consensus +++
Reference: [26]
Treatment with coagulation factors or platelets is indicated for patients with persistent severe peripartum bleeding (> 1500 ml) and evidence for a deficiency of coagulation factors or platelets.

Time plays an essential role in the diagnosis and treatment of PPH [187]. A deficiency of one or more coagulation factors can be diagnosed with parameters obtained by standard coagulation laboratory tests and viscoelastic tests (VET). However, standard laboratory/VET values are mainly useful to decide when substitution is not required [188]. The preventive administration of fibrinogen is not useful, not even in an obstetric setting [189].

11  Treatment algorithms

11.1  Atony

• Anticipate risk factors

• Diagnosis: increased fundal height; soft, relaxed uterus; usually intermittent surge-like bleeding

• Empty the bladder!

• Mechanical procedures: uterine massage (endogenous prostaglandin formation), bimanual uterine compression (e.g., Hamiltonʼs procedure)

Caution:

• 500 – 1000 ml of blood may collect in the uterine cavity → discrepancy between externally apparent level of bleeding and development of a serious loss of volume. In cases of uncertainty, attempt rapid clarification using ultrasound as long as this does not lead to delay

• Exclude birth trauma (speculum examination and abdominal US, if necessary)

• Exclude placental remnants (check placenta for completeness, ultrasound)

Consensus-based recommendation 11.E1
Expert consensus	Level of consensus +++
Reference: [26]
Treatment plan for atony: uterotonic drugs, tranexamic acid if necessary if placental remnants are present: curettage in the labour room or the operating room uterine tamponade if necessary additional surgical measures poss. embolization/balloon occlusion

11.2  Placenta accreta spectrum

• Anticipate risk factors (previous uterine surgery/curettage); in patients with prenatal suspicion of placentation disorder → care by a multidisciplinary team

• The management of placental detachment disorders depends on the time of diagnosis and the mode of delivery.

• Early interdisciplinary discussion/treatment plan is advisable.

Consensus-based statement 11.S1
Expert consensus	Level of consensus +++
References: [26], [190], [191], [192]
Important cornerstones when managing PAS! The treatment plan of a pregnant woman with PAS includes: constant access to blood products at short notice contingency to carry out complex pelvic surgery multidisciplinary team review case (repeatedly if necessary) with members of the team (the pregnant woman must be known; an individual treatment plan must be set up) 24-h availability of interdisciplinary surgical intensive care for the mother and a neonatology intensive care unit If these conditions cannot be met: the pregnant woman must be presented to a suitable centre.

Consensus-based recommendation 11.E2
Expert consensus	Level of consensus +++
Reference: [26]
Management recommendations for PAS: Multidisciplinary team with best possible expertise Multidisciplinary planning of the birth prepartum (elective caesarean section if possible) Ensure sufficient blood products/coagulation factors/ autotransfusion unit are available Management for elective delivery: Place adequate intravenous access points, volume substitution Place access points and occlusion balloon already preoperatively if necessary Laparotomy (longitudinal incision if necessary) Hook out the uterus if necessary Devascularisation of afferent vessels and dissection of the uterus from the bladder Intraoperative ultrasound if necessary to obtain the exact location of the placenta and position the uterotomy (at a sufficient distance to the placenta – transversely to the fundus) Delivery of the infant/cutting and clamping of the cord (caution: no traction on the placenta) Administer uterotonic drugs and tranexamic acid IV Ideally do not attempt to separate the placenta (risk of bleeding) – at most, if the situation is not clear (suspected PAS), carefully attempt to manually separate the placenta Individualised surgical procedure if necessary Autotransfusion in cases with high loss of blood Continuous antibiotic prophylaxis No administration of methotrexate

11.2.1.1  Extensive findings

• Caesarean section with hysterectomy, preferably without a prior attempt to deliver the placenta (total HE preferred)

• Alternatives:

  • Delayed hysterectomy following caesarean section if necessary

  • In individual cases, consider delaying delivery of the placenta (ideally in a centre with 24-h availability of an interdisciplinary surgical intensive care ward).

11.2.1.2  Focal findings

• Partial resection of the uterine wall while retaining the uterus in cases with locally limited implantation disorder.

• Focal intracavitary Z-sutures to achieve haemostasis in small areas of bleeding.

• Interventional radiology if necessary: prophylactic occlusion of the internal iliac arteries [193], [194].

11.2.2  Management following antenatal diagnosis

Consensus-based recommendation 11.E3
Expert consensus	Level of consensus +++
Reference: [26]
Pregnant women with suspected PAS (with/without placenta praevia) must be delivered in a perinatal centre with the relevant interdisciplinary expertise in managing PAS. Prenatal early presentation of the patient to the centre is strongly recommended.

11.2.3  Management with intrapartum diagnosis

11.2.3.1  Vaginal birth

In cases where the placenta fails to detach and bleeding is present → ultrasound evaluation and manual separation of the placenta, followed by curettage with intraoperative ultrasound monitoring, if necessary.

If severe bleeding from the placental bed persists → surgical treatment; alternatively, embolization of the uterine arteries.

11.2.3.2  Caesarean section

Consensus-based recommendation 11.E4
Expert consensus	Level of consensus +++
Reference: [26]
If diagnosed intraoperatively and mother and child are stable, emergency transportation of the patient to a centre with the relevant expertise should be considered. If this is not possible, care by the best experts available must be ensured without delay.

Do not manipulate the placenta if possible or attempt manual separation of the placenta!

Perform caesarean section with hysterectomy or alternatively delay delivery of the placenta (ideally in a centre with 24-h availability of an interdisciplinary surgical intensive care ward).

11.3  Uterine inversion

• Uterine inversion may occur both with vaginal delivery and caesarean section (caused by the uterotomy).

• Vaginal palpation: inverted intravaginal fundus.

• Abdominal palpation: no fundal resistance, cuplike invagination may be palpated.

• If the findings are not clear → ultrasound examination [195], [196].

Consensus-based recommendation 11.E5
Expert consensus	Level of consensus +++
References: [26], [197], [198], [199] (For images of the manoeuvres, see [26])
The goal is to reposition the uterus and treat the symptoms of haemorrhagic shock; The following measures must be carried out immediately after diagnosis and in the order given below: Stop administration of any uterotonic drugs Call in experienced obstetrician and anaesthesiologist Ensure adequate intravenous access, volume substitution Do not attempt to separate the placenta; because of the increased loss of blood, the placenta must, if possible (placenta accreta), only be delivered after repositioning. Attempt to reposition the fundus (Johnsonʼs manoeuvre) Consider general anaesthesia with the aim of relaxing the uterus If the attempt at repositioning fails, administer uterine relaxants (e.g., nitroglycerin 50 µg IV or hexoprenaline 10 µg IV) and carry out a new repositioning attempt using Johnsonʼs manoeuvre If the repositioning attempt continues to be unsuccessful → perform laparotomy and Huntingtonʼs procedure, simultaneously with Johnsonʼs manoeuvre if necessary; if the attempts are still unsuccessful, perform the Haultain procedure Administer uterotonic drugs (e.g., oxytocin) after successful repositioning Provide antibiotic protection (e.g., cephalosporin or clindamycin)

12  Transportation

Consensus-based recommendation 12.E1
Expert consensus	Level of consensus +++
References: [26], [200]
The facility transferring the patient and the facility accepting the patient should have already agreed on the timing of transportation and staff coverage during transportation in the run-up to the transfer and the agreement between the two facilities should be recorded in writing.

Consensus-based recommendation 12.E2
Expert consensus	Level of consensus +++
References: [26]
Transportation of a haemodynamically instable patient as part of the management of PPH should be weighed up carefully and depend on the organisational conditions in the facility providing care. The patient should preferably only be transferred after haemodynamic stabilisation.

12.1  Recommendations for managing the interface between non-hospital-based obstetric care/
hospital in cases with PPH

• Specific plans and arrangements must be agreed upon between the persons/facilities providing care (home-birth midwife, midwifery-led unit, hospital staff) before an emergency occurs and developed during joint team meetings or training courses. Arrangements must include professional exchanges on how the patient will be transported (who will be informed, how, and by whom) as well as the specific situation when handing over the patient (how will the patient be handed over and how will further communications be made).

• A joint approach to the transportation of patients should be agreed upon beforehand and should be communicated to the relevant regional institutions beforehand, including to the rescue coordination centre (description of procedures, emergency telephone numbers, contact persons).

• Jointly agreed terms, for example: “Acute danger to life of mother and/or child”, the specific diagnosis (e.g., placental abruption, PPH), “Please inform on-call consultants and staff”, “Please ensure the operating team is in readiness”, etc., ensure that communications will be effective and make it easier for the hospital to prepare for the emergency.

• Carry out a joint case review after an emergency which includes all persons providing care during the emergency to continually improve and optimise cooperation between non-hospital-based and hospital-based obstetric care as part of improving patient safety.

13  Monitoring after PPH

Consensus-based recommendation 13.E1
Expert consensus	Level of consensus +++
References: [26], [201], [202]
After a PPH, individually adapted monitoring must be carried out.

14  Documentation

Consensus-based recommendation 14.E1
Expert consensus	Level of consensus +++
Reference: [26]
Careful documentation of every event defined as an emergency is essential. The use of special forms developed for the respective organisational unit is recommended.

15  Debriefing

Consensus-based recommendation 15.E1
Expert consensus	Level of consensus +++
Reference: [26]
After PPH, the affected patient and her companion(s) must be offered a follow-up discussion using language comprehensible to non-medical specialists. The discussion must include a member of the obstetric team if necessary and be held in the first days postpartum. It should be documented for the patientʼs further outpatient care. The patient must be informed that the offer to have a discussion will hold good even after she has been discharged from hospital.

Consensus-based statement 15.S1
Expert consensus	Level of consensus +++
Reference: [26]
Interdisciplinary debriefing of the team is recommended.

Consensus-based recommendation 15.E2
Expert consensus	Level of consensus +++
References: [26]
A crisis intervention option should be available for the team; this applies particularly in cases where the outcome was fatal.

16  Training

Consensus-based recommendation 16.E1
Expert consensus	Level of consensus +++
References: [26], [203], [204], [205]
Structured simulations of peripartum haemorrhage and appropriate responses by an interdisciplinary team should be carried out regularly to improve the teamʼs technical und non-technical skills.

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Publication History

Received: 06 April 2023

Accepted: 09 April 2023

Article published online:
28 June 2023