Ultrasound-indicated versus systematic intrauterine manual examination in the management of postpartum hemorrhage: a before-and-after study

The use of intrauterine manual examination in the management of postpartum hemorrhage (PPH) varies widely across countries. French guidelines recommend systematic intrauterine manual examination, while American guidelines support ultrasound use. This study aimed to evaluate whether ultrasound-indicated intrauterine manual examination was associated with higher rates of severe PPH compared with systematic intrauterine manual examination.

We conducted a retrospective, single-center, before-and-after study including all women with vaginal delivery complicated by PPH. In the before period (January 1, 2020, to December 31, 2020), intrauterine manual examination was systematically recommended when PPH was diagnosed, whereas in the after period (January 1, 2022, to December 31, 2022) intrauterine manual examination was performed only when bedside ultrasound suggested retained placental tissue, defined as the presence of an echogenic mass within the uterus on a sagittal ultrasound. The primary outcome was the rate of severe PPH, defined as total quantified blood loss exceeding 1000 ml. Secondary outcomes included the need for blood transfusion, total quantified blood loss volume, and the need for additional uterotonics.

The implementation of ultrasound-indicated intrauterine manual examination significantly decreased the rate of intrauterine manual examination (64.2% vs. 29.1%, P <.01) without increasing the incidence of severe PPH (14.9% vs. 13.8%, P=.81). Total blood loss, transfusion rates, and the need for additional uterotonic were comparable between the two periods.

Ultrasound-indicated intrauterine manual examination reduced the rate of intrauterine manual examination without increasing the rate of severe PPH.