Implementation of the D-A-CH postpartum haemorrhage algorithm after severe postpartum bleeding accelerates clinical...

Implementation of the D-A-CH postpartum haemorrhage algorithm after severe postpartum bleeding accelerates clinical management: a retrospective observational case series. Jean-Jacques Ries, Lena Jeker, Michelle Neuhaus, Deborah R. Vogt, Thierry Girard, Irene Hoesli.

Postpartum haemorrhage (PPH) is a leading cause of maternal death and severe morbidity. The algorithm for the three German speaking countries ("D-A-CH Handlungsalgorithmus Postpartale Blutung") for the management of PPH was introduced in 2012 at the University Hospital Basel. The aim of this study was to compare the blood loss, the initiation and application of the clinical management of severe PPH (≥1000 ml) after vaginal deliveries before and after the implementation of the algorithm.

In this retrospective case series data were collected from a manual and an electronic database. The study was approved by the local ethical committee. Patients with an estimated blood loss of 1000 ml or more were included. The primary endpoint was the estimated total postpartum blood loss. Secondary endpoints were differences in pharmacological and surgical treatments, time from delivery to the initiation of a specific treatment and total costs. A propensity score analysis was performed to minimize potential bias between control and intervention group.

A total of 317 women were included, 141 women before (control group) and 176 women after the implementation of the algorithm (intervention group). Total postpartum blood loss did not differ between the groups (Median [IQR]: control group 1600 [1400, 2100] ml, intervention group 1500 [1400, 2000] ml). Use of sulprostone (OR 2.42 [1.52, 3.87], p = 0.004), tranexamic acid (OR 6.27 [3.65, 10.78], p < 0.001) and Bakri Balloon Tamponade® (BBT®) (OR 7.82 [2.68, 22.84], p = 0.004) and the application of rotational thromboelastoemtry (ROTEM®) (OR 32.37 [4.35, 240.56], p = 0.012) were significantly more frequent in the intervention group. In the intervention group tranexamic acid was administered significantly earlier (relative effect: 0.61 [0.50, 0.75], p < 0.001). No differences could be shown in haemoglobin concentration two days postpartum, transfer to the intensive care unit (ICU) or total costs of treatment.

The implementation of the D-A-CH algorithm in women after vaginal delivery with severe postpartum bleeding did not result in significantly reduced blood loss. However, it accelerated the clinical management and induced the application of a wider range of pharmacological interventions within a shorter interval after delivery without generating more costs.