Investigations
Your Organisational Guidance
ebpracticenet urges you to prioritise the following organisational guidance:
Multidisciplinaire richtlijn Postpartumzorg in de eerste lijn (deel 1)Published by: Werkgroep Ontwikkeling Richtlijnen Eerste Lijn (Worel)Last published: 2022Guideline multidisciplinaire des soins postnatals dans la première ligne de soins (partie 1)Published by: Groupe de Travail Développement de recommmandations de première ligneLast published: 2022Multidisciplinaire richtlijn Postpartumzorg in de eerste lijn (deel 2)Published by: Werkgroep Ontwikkeling Richtlijnen Eerste Lijn (Worel)Last published: 2024Guideline multidisciplinaire des soins postnatals dans la première ligne de soins (partie 2)Published by: Groupe de Travail Développement de recommmandations de première ligneLast published: 20241st investigations to order
quantification of blood loss
Test
Use an objective method to measure blood loss (e.g., by weighing blood-soaked drapes or surgical sponges).[71]
Weighing blood-soaked drapes or sponges is a more precise and objective approach that minimises the risk of underestimating blood loss and facilitates early identification and intervention for PPH.[71][85][86][87]
Visual estimation can result in underestimation of blood loss by 33% to 50%, particularly when large volumes are lost.[4][52]
Objective measurement of cumulative quantitative blood loss (QBL) - including the use of under-buttock drapes during vaginal births and real-time weight measurements of blood-soaked materials - is advocated by the World Health Organization (WHO) and International Federation of Gynecology and Obstetrics (FIGO) as an essential part of an obstetric haemorrhage detection and management bundle.[12][55][71]
The E-MOTIVE trial, published in 2023, assessed use of a calibrated drape for early detection of excessive blood loss following vaginal birth among 210,132 women in four African nations. Use of the drapes triggered an immediate treatment bundle for any woman with blood loss of ≥500 mL (as indicated by a red action line on the drapes) or with blood loss ≥300 mL (yellow warning line) together with hypotension or tachycardia. This combined PPH early detection and treatment bundle was associated with a 60% reduction in the composite primary outcome of severe PPH (blood loss ≥1000 mL), or laparotomy or maternal death from PPH (risk ratio 0.40, 95% CI 0.32 to 0.50; P <0.001) when compared with usual care.[91]
In response to the E-MOTIVE findings, the WHO commissioned a systematic review on methods to assess postpartum blood loss. This led to a recommendation to use an objective method to quantify blood loss in all women giving birth, such as calibrated drapes for those having vaginal birth.[71]
The WHO highlighted that to be effective in improving outcomes, objective approaches to quantifying blood loss must be combined with a standardised protocol to ensure prompt initiation of treatment immediately on detection of PPH.[71]
In guidance that predates publication of the E-MOTIVE trial results and the WHO recommendation, the UK Royal College of Obstetricians and Gynaecologists states that use of blood collection drapes for vaginal deliveries and the weighing of swabs is an option to address visual underestimation of blood loss.[4]
The American College of Obstetricians and Gynecologists has published tips for quantification of blood loss following vaginal and caesarean delivery.[92] See Diagnosis approach.
Result
≥500 mL
blood type and cross-match
Test
Send a stat blood sample for type and cross-match for any patient with suspected PPH to facilitate timely administration of blood product replacement, if indicated.[4][21][53]
Notify the blood bank so that at least 2 units of blood can be type and cross-matched for the patient.[21]
Result
blood type in preparation for transfusion
FBC
Test
Order an FBC to assess the degree of acute blood loss anaemia.[4][53] Be aware that an initial FBC at the time of PPH may not accurately reflect the degree of ongoing blood loss.[3][21]
Blood transfusion must not be delayed for the results of an FBC, nor deferred in the setting of a normal initial FBC despite the presence of clinical signs and symptoms of significant PPH.[3][21]
Result
significant decrease from baseline haemoglobin/haematocrit level (if available)
coagulation profile (PT, PTT, INR, fibrinogen)
Test
Request a coagulation profile to assess for underlying or developing coagulopathy in any patient with significant PPH.[2][4][53] This is especially important if disseminated intravascular coagulation (DIC) or another inherited or acquired coagulopathy is suspected.[21]
Early identification of coagulation abnormalities can aid in the timely administration of appropriate blood products or adjunctive medical therapies.[21]
Result
abnormal if DIC is present; elevated PT/PTT/INR; decreased fibrinogen
Investigations to consider
uterine ultrasound
Test
Bedside ultrasonography can be used to assess the endometrial stripe for the presence of retained intrauterine placental tissue, although the diagnosis of retained products is unreliable.[3][4]
Ultrasound is particularly important in investigation of secondary PPH, which can be caused by retained products of conception.
[Figure caption and citation for the preceding image starts]: Ultrasound image showing retained product of conception within the endometrial cavity (measuring 20 x 8mm) in a woman with secondary PPH. The image was taken on day 22 post-deliveryDu R, et al. BMJ Case Reports CP 2021;14:e245009; used with permission [Citation ends].
Result
echogenic mass if placental tissue has been retained
inherited coagulation assays
Test
Testing for inherited coagulopathies can be considered for patients with abnormal coagulation profiles or a family history of hereditary coagulopathy.[3]
Result
identification of an inherited coagulopathy such as von Willebrand disease, haemophilia A, or haemophilia B
diagnostic laparotomy
Test
In patients with refractory PPH, a laparotomy may be performed to further evaluate the pelvic and abdominal organs.[82]
Result
identification of concealed haemorrhage source such as broad ligament and retroperitoneal haematomas
CT abdomen/pelvis
Test
CT with contrast can determine whether ongoing haemorrhage is present and identify the source. Further evaluation with CT may be appropriate in haemodynamically stable patients when conventional medical treatments have failed to control bleeding.[93]
Result
may detect less common underlying cause of PPH, e.g., intra-abdominal haemorrhage; uterine rupture (suggested by presence of gas in the myometrial defect extending from the endometrium to the parametrial tissue, along with haemoperitoneum)
vaginal microbiology (secondary PPH)
Emerging tests
thromboelastography (TEG) or rotational thromboelastometry (ROTEM®)
Test
Rapid point-of care tests that can be used for the evaluation of coagulopathy. Increasingly used in obstetric intensive care units to guide transfusion needs and uncover the underlying factors contributing to coagulopathy in patients experiencing PPH.[36][94][95]
TEG and ROTEM offer distinct advantages over standard coagulation assays by enabling the evaluation of coagulation using whole blood, thereby facilitating rapid and precise detection of coagulation abnormalities, proving particularly invaluable in cases of ongoing haemorrhage. However, their use is limited by the absence of standardised normal reference ranges.[96][97][98][99]
Result
abnormal coagulation index if coagulopathy is present (but standardised reference ranges have yet to be established for different patient groups)
app-based blood loss quantification technology
Test
Innovative app-based techniques supported by artificial intelligence (e.g., the US Food and Drug Administration-approved Triton System™) have emerged to enhance the measurement of ongoing blood loss. Leveraging mobile monitoring capabilities, the Triton System™ captures images of blood-soaked surgical materials and employs feature extraction technology to provide accurate haemoglobin measurements.[100][101] While the potential benefits of this technology are promising, its long-term efficacy in the context of obstetric care requires further evaluation.
Result
≥500 mL
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