Hemostatic assessment, treatment strategies, and hematology consultation in massive postpartum hemorrhage: results of a quantitative survey of obstetrician-gynecologists

Abstract

Objective: To assess potential diagnostic and practice barriers to successful management of massive postpartum hemorrhage (PPH), emphasizing recognition and management of contributing coagulation disorders.

Study design: A quantitative survey was conducted to assess practice patterns of US obstetrician-gynecologists in managing massive PPH, including assessment of coagulation.

Results: Nearly all (98%) of the 50 obstetrician-gynecologists participating in the survey reported having encountered at least one patient with "massive" PPH in the past 5 years. Approximately half (52%) reported having previously discovered an underlying bleeding disorder in a patient with PPH, with disseminated intravascular coagulation (88%, n=23/26) being identified more often than von Willebrand disease (73%, n=19/26). All reported having used methylergonovine and packed red blood cells in managing massive PPH, while 90% reported performing a hysterectomy. A drop in blood pressure and ongoing visible bleeding were the most commonly accepted indications for rechecking a "stat" complete blood count and coagulation studies, respectively, in patients with PPH; however, 4% of respondents reported that they would not routinely order coagulation studies. Forty-two percent reported having never consulted a hematologist for massive PPH.

Conclusion: The survey findings highlight potential areas for improved practice in managing massive PPH, including earlier and more consistent assessment, monitoring of coagulation studies, and consultation with a hematologist.

Keywords: acquired hemophilia; blood coagulation disorders; disseminated intravascular coagulation; von Willebrand disease.

Figure 1

Strategies utilized by surveyed obstetrician-gynecologists (n=50) for postpartum hemorrhage. Notes: (A) Uterotonics, (B) surgical management, and (C) blood or factor products. Participants were advised to select as many strategies as applied. Abbreviations: FFP, fresh frozen plasma; PRBCs, packed red blood cells.

Figure 2

Prior hematology consultation by survey participants. Notes: (A) Prior frequency of hematology consultation by survey participants specifically for postpartum hemorrhage (n=50) and (B) reasons participants would consider consulting a hematologist for this purpose (n=29). Participants were advised to select as many reasons for considering a hematology consultation as applied. Abbreviations: DIC, disseminated intravascular coagulation; FFP, fresh frozen plasma.