BMJ 2017;358:j3875 doi: 10.1136/bmj.j3875 (Published 27 September 2017) Page 1 of 6 Practice CLINICAL UPDATES Diagnosis and management of postpartum haemorrhage Edwin Chandraharan consultant obstetrician and gynaecologist, lead clinician of labour ward, and 1 2 1 honorary senior lecturer , Archana Krishna specialist registrar in obstetrics and gynaecology St George’s University Hospitals NHS Foundation Trust, London SW17 0QT, UK; 2St George’s University of London, London, UK 1 Postpartum haemorrhage is a major cause of death during pregnancy and early motherhood, accounting for 25% of maternal deaths worldwide,1 and is the second leading direct cause of maternal deaths in the UK.2 It is defined as blood loss of more than 500 mL from the female genital tract after delivery of the fetus (or >1000 mL after a caesarean section). Primary postpartum haemorrhage occurs within the first 24 hours of delivery, whereas secondary postpartum haemorrhage occurs between 24 hours and 12 weeks after delivery and is less common.1 For every maternal death due to postpartum haemorrhage, there are at least 10 “near-misses.” Serious maternal morbidities include multiorgan failure, multiple blood transfusion, and peripartum hysterectomy.1 There have been recent advances in the management of postpartum haemorrhage secondary to coagulopathy and abnormal invasion of the placenta.3 This review highlights the causes, diagnosis, and management of postpartum haemorrhage and is aimed at those involved in obstetric and postnatal care. What are the mechanisms of and risk factors for postpartum haemorrhage? Atonic postpartum haemorrhage secondary to a poor tone of the uterine muscle accounts for approximately 80% of all women with excessive bleeding from the genital tract within 24 hours of delivery.4 Women who have had prolonged labour, multiple pregnancy, polyhydramnios, a large fetus, obesity, or pyrexia during labour are all at increased risk.5 Rare causes of primary postpartum haemorrhage include uterine inversion, placenta percreta (fig 1⇓), as well as extra-genital bleeding. The commonest cause of secondary postpartum haemorrhage is endometritis. It is estimated that over 85% of women who have a vaginal birth will sustain some degree of perineal trauma, and, of these, 60-70% will need to be sutured.6 7 An episiotomy itself can increase the risk of postpartum haemorrhage by up to fivefold.8 Emergency caesarean sections were associated with an approximately threefold increase in postpartum haemorrhage compared with elective caesarean sections or spontaneous vaginal births.9 A population based, cohort nested, case-control study has concluded that, after adjustment for all potential confounders, intrapartum use of oxytocin was associated with a significantly higher risk of severe postpartum haemorrhage (adjusted odds ratio 1.8 (95% confidence interval 1.3 to 2.6)) in women who did not receive prophylactic oxytocin after delivery; the odds ratio for haemorrhage increased from 1 to 5 according to the level of oxytocin exposure.10 It is postulated that this is due to excessive uterine contractions and resultant lactic acidosis in the uterine muscle as well as prolonged labour, when oxytocin is used to augment labour. How is primary postpartum haemorrhage assessed and diagnosed? Examination and resuscitation Attempt to identify the cause in women who are bleeding immediately after birth in parallel with resuscitation. The infographic suggests an approach to management adapted from the Royal College of Obstetricians and Gynaecologists Green-top Guideline on postpartum haemorrhage.5 Further assessment It is important to perform a systematic examination immediately after birth11 so that specific treatments can be instituted (see infographic). Correspondence to: E Chandraharan [email protected] Data supplements on bmj.com (see http://www.bmj.com/content/358/bmj.j3875?tab=related#datasupp) Infographic: Suggested approach to management of postpartum haemorrhage based on possible causes For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe BMJ: first published as 10.1136/bmj.j3875 on 27 September 2017. 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PRACTICE BMJ 2017;358:j3875 doi: 10.1136/bmj.j3875 (Published 27 September 2017) Page 2 of 6 PRACTICE • Postpartum haemorrhage remains the second leading direct cause of maternal deaths in the UK and the leading cause of maternal mortality in the world • Poor uterine tone accounts for about 80% of all cases of primary postpartum haemorrhage, whereas endometritis is the commonest cause of secondary postpartum haemorrhage presenting up to 12 weeks after delivery • Tranexamic acid is recommended for all women with atonic and traumatic postpartum haemorrhage as well as for ongoing haemorrhage during a caesarean section • Refer women with secondary postpartum haemorrhage after birth for ultrasonography to exclude retained products of conception or endometritis • Start broad spectrum antibiotics in women with secondary postpartum haemorrhage due to endometritis Sources and selection criteria We searched PubMed using the key words “postpartum haemorrhage,” “balloon tamponade,” “uterine compression suture,” “embolization,” and “obstetric haemorrhage” from 1981 to 2016. We also considered review articles from 2001 to 2016 including systematic and narrative reviews as well as the most recent Cochrane systematic review on treatment for primary postpartum haemorrhage.21 Priority was given to randomised controlled trials and four large prospective series. Any delay in achieving haemostasis after birth can result in major loss of maternal blood volume, leading to hypotension, hypoxia, and acidosis. The blood flow to the uterus at term (that is, >37 weeks of gestation) is approximately 1000 mL of blood every minute, and a fetus at term receives about 200 mL/kg/minute from the placenta.12 Estimating the amount of blood that has been actually lost in postpartum haemorrhage visually is prone to error.13 An obstetric shock index (that is, pulse rate divided by systolic blood pressure) of >1 has been shown to be associated with substantial postpartum haemorrhage and the need for intensive resuscitation and blood transfusion.14 15 In our clinical opinion, an obstetric shock index of >1 would indicate the need for immediate action to ensure haemodynamic stability. A management algorithm called HAEMOSTASIS has been proposed to aid a systematic and stepwise management of postpartum haemorrhage (box 1),11 and a recent retrospective observational study has suggested that the use of this algorithm has helped improve outcomes and reduced the likelihood of peripartum hysterectomy.16 “HAEMO” refers to the immediate measures to be taken to arrest haemorrhage, while “STASIS” represents the more advanced measures (box 1). Intra-abdominal bleeding secondary to an extragenital cause such as the rupture of the liver or spleen is uncommon, but may be more likely in women with severe pre-eclampsia due to rupture of the hepatic capsule. If a woman remains unresponsive to treatment or if the amount of visible blood loss is less than the observed haemodynamic instability, we recommend an ultrasound scan to investigate a possible intra-abdominal cause. How is postpartum haemorrhage managed? It is important to identify both antepartum and postpartum risk factors that might predispose women to postpartum bleeding—such as placenta praevia, uterine fibroids, and retained placenta—as outlined in the infographic. Planning ahead involves input from a multidisciplinary team to ensure that experienced clinicians are present at the birth and there are suitable blood products available. Active management of the third stage of labour is the process by which expulsion of the placenta and membranes is achieved after delivery by uterine massage, controlled cord traction, and the use of oxytocin as well as other drugs. A randomised controlled trial showed that active management of the third stage alone reduces the incidence of primary For personal use only: See rights and reprints http://www.bmj.com/permissions postpartum haemorrhage by 70% compared with physiological management alone.17 Clinical guidelines on postpartum haemorrhage continue to recommend mechanical methods such as bimanual compression or emptying the urinary bladder based on consensus of professional opinion.5 What drugs are used in the medical management of primary postpartum haemorrhage? Oxytocin is the most commonly used drug in the medical management of postpartum haemorrhage. Other drugs are listed in box 2. The incidence of postpartum hypertension has been found to be significantly lower in women who received carbetocin compared with those who received syntometrine.23 Therefore, ergometrine and syntometrine should be avoided in women with hypertension and pre-eclampsia to avoid the risk of stroke. Although, injectable prostaglandins (prostaglandin F2α and its synthetic analogue carboprost tromethamine) have been used as an adjunct to oxytocin in the management of atonic postpartum haemorrhage, they have not been subjected to any randomised controlled trials. Despite the lack of robust scientific evidence, most clinical guidelines recommend the use of injectable prostaglandins in the management algorithm, up to eight doses 15 minutes apart of 250 μg given intramuscularly.5 Use prostaglandins with caution in patients with bronchial asthma as it is not recommended as an intra-myometrial injection.5 A recent Cochrane systematic review of 10 randomised controlled trials reported that, compared with placebo, treatment with tranexamic acid (1 g intravenous) reduced blood loss in women with atonic postpartum haemorrhage,21 and therefore tranexamic acid is recommended for atonic and traumatic postpartum haemorrhage as well as ongoing haemorrhage during a caesarean section.5 What is the role of a uterine tamponade balloon? A recent systematic review, which included 241 women, has concluded that the insertion of a uterine tamponade balloon to control bleeding is effective in 97% of cases of postpartum haemorrhage.24 The authors suggested that it would be logical to use this least invasive, easiest, and most rapid approach as the first step in the management of intractable postpartum haemorrhage after the failure of pharmacological treatment. Subscribe: http://www.bmj.com/subscribe BMJ: first published as 10.1136/bmj.j3875 on 27 September 2017. Downloaded from http://www.bmj.com/ on 11 December 2018 by guest. Protected by copyright. What you need to know BMJ 2017;358:j3875 doi: 10.1136/bmj.j3875 (Published 27 September 2017) Page 3 of 6 PRACTICE H—Ask for help and hands on uterus (uterine massage) A—Assess (that is, ABC) and resuscitate (that is, intravenous fluids) E—Establish aetiology, ensure availability of blood, and ecbolics (drugs that induce contractions of the uterus, oxytocin or ergometrine) M—Massage the uterus O—Oxytocin infusion (10 U/hour) or intramuscular prostaglandins (250 μg) S—Shift to theatre, with aortic compression, bimanual compression, or anti-shock garment (for low resource settings before transfer to a tertiary centre) as appropriate T—Tamponade by balloon or uterine packing after exclusion of retained tissue and trauma. Administer intravenous tranexamic acid (1 g) A—Apply compression sutures on the uterus (B-Lynch or modified technique) S—Systematic pelvic devascularisation (uterine, ovarian, quadruple. or internal iliac) I—Interventional radiology and, if appropriate, uterine artery embolisation S—Subtotal or total abdominal hysterectomy Box 2: Drugs used in treatment of postpartum haemorrhage (source: BNF Online June 2017) First line drugs Oxytocin (octapeptide which is secreted by the supraoptic and paraventricular nuclei of the hypothalamus and is stored in the posterior pituitary gland) Mode of action—Myometrial contraction and retraction; increases basal uterine tone Side effects—Nausea, vomiting, headache Ergometrine (ergot alkaloid) First line drug in developing countries Mode of action—Arterial vasoconstriction and myometrial contraction Side effects—Vomiting, headache, hypertension, chest pain, palpitations, bradycardia, Raynaud’s syndrome, pulmonary oedema18 Second line drugs Tranexamic acid Mode of action—Antifibrinolytic which prevents the breakdown of preformed blood clot and therefore stabilises the clot Side effects—Hypotension, diarrhoea, thromboembolic events Recent Cochrane review of 10 randomised controlled trials (RCTs) reported that blood losses >400 mL or >500 mL and >1000 mL were less common in women who received tranexamic acid compared with placebo or no intervention (risk ratios 0.52 (95% confidence interval 0.42 to 0.63) and 0.40 (0.23 to 0.71), respectively)19 Misoprostol (prostaglandin analogue)20 Mode of action—Myometrial contraction Side effects—Diarrhoea, rash, dizziness, vomiting21 Not found to be effective after administration of oxytocin21 and may increase adverse effects22 Prostaglandins F2α Mode of action—Myometrial contraction Side effects—Bronchospasm, cardiovascular system collapse, dyspnoea, hypertension, vomiting, pulmonary oedema No robust evidence of effectiveness Carbetocin (synthetic oxytocin analogue) Mode of action—Myometrial contraction Side effects—Diarrhoea, hypotension Cochrane review of 11 RCTs concluded that use of carbetocin statistically significantly reduced the need for therapeutic uterotonics (risk ratio 0.62 (0.44 to 0.88) compared with oxytocin for women who underwent caesarean section but not for vaginal delivery.23 There was no robust evidence to suggest that carbetocin was better than oxytocin in reducing postpartum haemorrhage, and its cost effectiveness remains unclear Syntometrine (combination of 5 units of oxytocin and 0.5 mg of ergometrine) Mode of action—Myometrial contraction Side effects—Nausea, vomiting, diarrhoea Cochrane review of 4 RCTs that compared carbetocin and syntometrine showed a lower mean blood loss in women who received carbetocin (mean difference −48.84 mL (95% CI −94.82 to −2.85 mL)23 However, this systematic review did not include any randomised controlled trials and therefore the conclusion should be interpreted with caution. What are the surgical treatment options for managing primary postpartum haemorrhage? Some women may need examination under anaesthesia to repair tears or trauma to the genital tract and the uterus, evacuation of retained products, insertion of balloon for tamponade, or drainage of a haematoma.25 Surgery may also be needed in case For personal use only: See rights and reprints http://www.bmj.com/permissions of bleeding that is not responsive to volume resuscitation and pharmacological treatment. Some women may need an exploratory laparotomy in order to insert compression sutures and to manage uncommon extra-genital sources of bleeding such as rupture of splenic artery aneurysm.26 27 Women who remain unresponsive to resuscitation despite measures aimed at controlling the ongoing haemorrhage may need a hysterectomy as a lifesaving measure.5 In centres where blood and blood products are not readily available, hysterectomy may be considered earlier to avoid dilutional coagulopathy Subscribe: http://www.bmj.com/subscribe BMJ: first published as 10.1136/bmj.j3875 on 27 September 2017. Downloaded from http://www.bmj.com/ on 11 December 2018 by guest. Protected by copyright. Box 1: HAEMOSTASIS algorithm for management of postpartum haemorrhage16 BMJ 2017;358:j3875 doi: 10.1136/bmj.j3875 (Published 27 September 2017) Page 4 of 6 PRACTICE How is secondary postpartum haemorrhage managed? As secondary postpartum haemorrhage occurs anytime between 24 hours and 12 weeks after delivery (most commonly between day 7 and day 14), it is important that clinicians working in community health settings are able to diagnose and manage it (see box 3). History and assessment Consider the possibility of retained products of conception or endometritis in women with a history of manual removal of placenta or prolonged rupture of membranes, prolonged labour, or pyrexia during labour. Refer these women for an ultrasound scan to exclude retained products of conception. Start broad spectrum antibiotics in women with secondary postpartum haemorrhage due to endometritis. Retained products of conception may require surgical evacuation.5 What’s new in the management of postpartum haemorrhage? Tranexamic acid The international, randomised, double blind, placebo controlled WOMAN trial reported that tranexamic acid reduces death due to bleeding in women with postpartum haemorrhage with no adverse effects.27 This is consistent with the findings in surgery and trauma (CRASH-2 trial).28 Therefore, based on the recent WOMAN trial, tranexamic acid is recommended in the routine management of postpartum haemorrhage unless there are specific contra-indications. Blood and blood products A recent randomised controlled trial (PROPPR trial, 2015) reported that initial infusion with plasma, platelets, and red blood cells in a 1:1:1 ratio did not improve overall survival compared with a 1:1:2 ratio in patients who had had or were at risk of massive blood loss.29 However, in additional analyses, more patients in the 1:1:1 group were reported to achieve “anatomic” haemostasis (objective assessment by the surgeon indicating that bleeding within the surgical field was controlled and no further haemostatic interventions were anticipated), and fewer patients may have died due to exsanguination by 24 hours. A 1:1 transfusion ratio of plasma to red blood cells is recommended, especially if bleeding is not under control.5 In acute emergencies where group-specific cross-matched blood is not readily available, consider O− “un-cross-matched” blood. Abnormal invasion of the placenta Abnormal and deep invasion of the placenta into the uterine myometrium (fig 1⇓) is associated with serious maternal morbidity and mortality secondary to massive obstetric haemorrhage.30 It has traditionally been managed with peripartum hysterectomy or intentional retention of placenta. However, a new conservative surgical technique called the triple P procedure has been described31 with good outcomes.32 Contributors: EC and AK designed the manuscript and AK performed the literature search. EC and AK co-wrote the manuscript, and EC is the guarantor and takes overall responsibility for the manuscript. For personal use only: See rights and reprints http://www.bmj.com/permissions Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare. Provenance and peer review: Commissioned; externally peer reviewed. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 World Health Organization. WHO recommendations for the prevention and treatment of postpartum haemorrhage. WHO, 2012. http://apps.who.int/iris/bitstream/10665/75411/1/ 9789241548502_eng.pdf Knight M, Tuffnell D, Kenyon S, Shakespeare J, Gray R, Kurinczuk JJ (eds) on behalf of MBRRACE-UK. Saving lives, improving mothers’ care: Surveillance of maternal deaths in the UK 2011-13 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-13. National Perinatal Epidemiology Unit, 2015. Chandraharan E, Arulkumaran S. Massive postpartum haemorrhage and management of coagulopathy. Obstetrics, Gynaecol Reprod Med 2007;17:119-22doi:10.1016/j.ogrm. 2007.02.004. Arulkumaran S, Decruz B. Surgical management of severe postpartum haemorrhage. Curr Obstet Gynaecol 1999;9:101-5doi:10.1016/S0957-5847(99)90008-2. Mavrides E, Allard S, Chandraharan E, et al. Prevention and management of postpartum haemorrhage: Green-top Guideline No 52. BJOG 2016;124:e106-49.pmid:27981719. McCandlish R, Bowler U, van Asten H, et al. A randomised controlled trial of care of the perineum during second stage of normal labour. Br J Obstet Gynaecol 1998;105:1262-72. doi:10.1111/j.1471-0528.1998.tb10004.x pmid:9883917. Sleep J, Grant A, Garcia J, Elbourne D, Spencer J, Chalmers I. West Berkshire perineal management trial. Br Med J (Clin Res Ed) 1984;289:587-90. doi:10.1136/bmj.289.6445. 587 pmid:6432201. Combs CA, Murphy EL, Laros RK Jr. Factors associated with postpartum hemorrhage with vaginal birth. Obstet Gynecol 1991;77:69-76.pmid:1984230. Brace V, Kernaghan D, Penney G. Learning from adverse clinical outcomes: major obstetric haemorrhage in Scotland, 2003-05. BJOG 2007;114:1388-96. doi:10.1111/j.1471-0528. 2007.01533.x pmid:17949379. Belghiti J, Kayem G, Dupont C, Rudigoz RC, Bouvier-Colle MH, Deneux-Tharaux C. Oxytocin during labour and risk of severe postpartum haemorrhage: a population-based, cohort-nested case-control study. BMJ Open 2011;1:e000514. doi:10.1136/bmjopen2011-000514 pmid:22189353. Chandraharan E, Arulkumaran S. Management algorithm for atonic postpartum haemorrhage. J Paediatr Obstet Gynaecol 2005;31:106-12. Ferrazzi E, Rigano S, Padoan A, Boito S, Pennati G, Galan HL. Uterine artery blood flow volume in pregnant women with an abnormal pulsatility index of the uterine arteries delivering normal or intrauterine growth restricted newborns. Placenta 2011;32:487-92. doi:10.1016/j.placenta.2011.04.004 pmid:21531458. Bose P, Regan F, Paterson-Brown S. Improving the accuracy of estimated blood loss at obstetric haemorrhage using clinical reconstructions. BJOG 2006;113:919-24. doi:10. 1111/j.1471-0528.2006.01018.x pmid:16907938. Le Bas A, Chandraharan E, Addei A, Arulkumaran S. Use of the “obstetric shock index” as an adjunct in identifying significant blood loss in patients with massive postpartum hemorrhage. Int J Gynaecol Obstet 2014;124:253-5. doi:10.1016/j.ijgo.2013.08.020 pmid: 24373705. Nathan HL, El Ayadi A, Hezelgrave NL, et al. Shock index: an effective predictor of outcome in postpartum haemorrhage?BJOG 2015;122:268-75. doi:10.1111/1471-0528.13206 pmid: 25546050. Varatharajan L, Chandraharan E, Sutton J, Lowe V, Arulkumaran S. Outcome of the management of massive postpartum hemorrhage using the algorithm “HEMOSTASIS”. Int J Gynaecol Obstet 2011;113:152-4. doi:10.1016/j.ijgo.2010.11.021 pmid:21396642. Prendiville WJ, Harding JE, Elbourne DR, Stirrat GM. The Bristol third stage trial: active versus physiological management of third stage of labour. BMJ 1988;297:1295-300. doi: 10.1136/bmj.297.6659.1295 pmid:3144366. Prata N, Bell S, Weidert K. Prevention of postpartum hemorrhage in low-resource settings: current perspectives. Int J Womens Health 2013;5:737-52. doi:10.2147/IJWH.S51661 pmid: 24259988. Novikova N, Hofmeyr GJ, Cluver C. Tranexamic acid for preventing postpartum haemorrhage. Cochrane Database Syst Rev 2015;(6):CD007872. doi:10.1002/14651858. CD007872.pub3. pmid:26079202. Elati A, Weeks A. Misoprostol for the management of postpartum haemorrhage. BMJ 2011;342:d2877. doi:10.1136/bmj.d2877 pmid:21571915. Mousa HA, Blum J, Abou El Senoun G, Shakur H, Alfirevic Z. Treatment for primary postpartum haemorrhage. Cochrane Database Syst Rev 2014;(2):CD003249. doi:10. 1002/14651858.CD003249.pub3. pmid:24523225. Quibel T, Ghout I, Goffinet F, et al. Groupe de Recherche en Obstétrique et Gynécologie (GROG). Active management of the third stage of labor with a combination of oxytocin and misoprostol to prevent postpartum hemorrhage: a randomized controlled trial. Obstet Gynecol 2016;128:805-11. doi:10.1097/AOG.0000000000001626 pmid:27607864. Su LL, Chong YS, Samuel M. Carbetocin for preventing postpartum haemorrhage. Cochrane Database Syst Rev 2012;(2):CD005457. doi:10.1002/14651858.CD005457. pub3. pmid:22336812. Tindell K, Garfinkel R, Abu-Haydar E, et al. Uterine balloon tamponade for the treatment of postpartum haemorrhage in resource-poor settings: a systematic review. BJOG 2013;120:5-14. doi:10.1111/j.1471-0528.2012.03454.x pmid:22882240. Chandraharan E, Arulkumaran S. Surgical aspects of postpartum haemorrhage. Best Pract Res Clin Obstet Gynaecol 2008;22:1089-102. doi:10.1016/j.bpobgyn.2008.08. 001 pmid:18790675. Doumouchtsis SK, Papageorghiou AT, Arulkumaran S. Systematic review of conservative management of postpartum hemorrhage: what to do when medical treatment fails. Obstet Gynecol Surv 2007;62:540-7. doi:10.1097/01.ogx.0000271137.81361.93 pmid:17634155. WOMAN Trial Collaborators. 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. Lancet 2017;389:2105-16. doi:10.1016/S0140-6736(17)30638-4 pmid:28456509. Roberts I, Shakur H, Coats T, et al. The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients. Health Technol Assess 2013;17:1-79. doi:10.3310/hta17100 pmid:23477634. Holcomb JB, Tilley BC, Baraniuk S, et al. PROPPR Study Group. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe Subscribe: http://www.bmj.com/subscribe BMJ: first published as 10.1136/bmj.j3875 on 27 September 2017. Downloaded from http://www.bmj.com/ on 11 December 2018 by guest. Protected by copyright. secondary to the excessive transfusion of intravenous fluids as well as the loss of platelets, fibrinogen, and clotting factors (that is, the “washout phenomenon”). BMJ 2017;358:j3875 doi: 10.1136/bmj.j3875 (Published 27 September 2017) Page 5 of 6 PRACTICE • Secondary postpartum haemorrhage occurs after the first 24 hours following childbirth and is most commonly due to endometritis or retained products of conception • Consider secondary postpartum haemorrhage in women who have excessive bleeding (that is, passage of clots or continuous bleeding) which is more than the normal lochia after childbirth • Check the woman’s temperature and exclude uterine tenderness, offensive vaginal discharge, or failure of uterine involution • Refer to an obstetrician for an early clinical assessment and ultrasound scanning to exclude retained products of conception Education into practice • If a woman presents with vaginal bleeding up to 12 weeks after delivery in the community, do you palpate her abdomen for uterine size, tone, and tenderness? The uterus should not be palpable per abdomen by day 14; a palpable uterus at this stage should make you suspect endometritis or retained products of conception. • How can you ensure that women who have a primary postpartum haemorrhage on their discharge summary receive specific follow-up to assess their bleeding, their haemoglobin levels, and monitor oral iron supplementation? Do you have a local pathway in place to support this, and if not, can you create one? Educational resources • Royal College of Obstetricians and Gynaecologists. Postpartum haemorrhage, prevention and management (Green-top Guideline No 52). RCOG Press, 2016. www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg52/ • World Health Organization. WHO recommendations for the prevention and treatment of postpartum haemorrhage. WHO, 2012. http: //apps.who.int/iris/bitstream/10665/75411/1/9789241548502_eng.pdf • Hunt BJ, Allard S, Keeling D, et al. A practical guideline for the haematological management of major haemorrhage. Br J Haematol 2015;170:788-803. doi:10.1111/bjh.13580 How patients were involved in the creation of this article No patients were involved in the creation of this article. 30 31 trauma: the PROPPR randomized clinical trial. JAMA 2015;313:471-82. doi:10.1001/jama. 2015.12 pmid:25647203. Khong TY, Robertson WB. Placenta creta and placenta praevia creta. Placenta 1987;8:399-409. doi:10.1016/0143-4004(87)90067-1 pmid:3684969. Chandraharan E, Rao S, Belli AM, Arulkumaran S. The Triple-P procedure as a conservative surgical alternative to peripartum hysterectomy for placenta percreta. Int J Gynaecol Obstet 2012;117:191-4. doi:10.1016/j.ijgo.2011.12.005 pmid:22326782. For personal use only: See rights and reprints http://www.bmj.com/permissions 32 Teixidor Viñas M, Belli AM, Arulkumaran S, Chandraharan E. Prevention of postpartum hemorrhage and hysterectomy in patients with morbidly adherent placenta: a cohort study comparing outcomes before and after introduction of the Triple-P procedure. Ultrasound Obstet Gynecol 2015;46:350-5. doi:10.1002/uog.14728 pmid:25402727. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/ permissions Subscribe: http://www.bmj.com/subscribe BMJ: first published as 10.1136/bmj.j3875 on 27 September 2017. Downloaded from http://www.bmj.com/ on 11 December 2018 by guest. Protected by copyright. Box 3: Tips for non-specialists BMJ 2017;358:j3875 doi: 10.1136/bmj.j3875 (Published 27 September 2017) Page 6 of 6 PRACTICE BMJ: first published as 10.1136/bmj.j3875 on 27 September 2017. Downloaded from http://www.bmj.com/ on 11 December 2018 by guest. Protected by copyright. Figure Fig 1 Placenta percreta invading the uterine myometrium and the serosa For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe