Tests
Your Organizational Guidance
ebpracticenet urges you to prioritize the following organizational 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 tests 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).[10][21]
Weighing blood-soaked sponges and drapes is a more precise and objective approach that minimizes the risk of underestimating blood loss and facilitates early identification and intervention for PPH.[80][81][82]
Visual estimation can result in underestimation of blood loss by 33% to 50%, particularly when large volumes are lost.[3]
The American College of Obstetricians and Gynecologists (ACOG) recommends the adoption of cumulative quantitative blood loss (QBL) as a valuable tool for attempting to quantify and achieve more accurate measurements of ongoing blood loss, as well as for facilitating effective communication among multidisciplinary teams.[10]
Objective measurement of cumulative QBL - including the use of under-buttock drapes during vaginal births and real-time weight measurements of blood-soaked materials - is advocated by the California Maternal Quality Care Collaborative and the World Health Organization (WHO) as an essential part of an obstetric hemorrhage detection and management toolkit.[53][72]
Some studies have cast doubt on the effectiveness of QBL measurements in preventing PPH or improving maternal outcomes.[83][84] There is no robust evidence demonstrating a reliable correlation between QBL measurements and postpartum hemoglobin measurements.[85]
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.[86]
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.[72] The WHO highlighted that to be effective in improving outcomes, objective approaches to quantifying blood loss must be combined with a standardized protocol to ensure prompt initiation of treatment immediately on detection of PPH.[72]
ACOG has published tips for quantification of blood loss.[10] See Diagnosis approach.
Result
≥1000 mL
blood type and crossmatch
Test
Send a stat blood sample for type and crossmatch for any patient with suspected PPH to facilitate timely administration of blood product replacement, if indicated.[21]
Notify the blood bank so that at least 2 units of blood can be type and crossmatched for the patient.[21]
Result
blood type in preparation for transfusion
Tests to consider
CBC
Test
Consider ordering a CBC to assess the degree of acute blood loss anemia, although an initial CBC at the time of PPH may not accurately reflect the degree of ongoing blood loss.[2][21]
Blood transfusion must not be delayed for the results of a CBC, nor deferred in the setting of a normal initial CBC despite the presence of clinical signs and symptoms of significant PPH.[2][21]
Result
significant decrease from baseline hemoglobin/hematocrit level (if available)
uterine ultrasound
Test
Bedside ultrasonography can be used to assess the endometrial stripe for the presence of retained intrauterine placental tissue.[2][87]
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
coagulation profile (PT, PTT, INR, fibrinogen)
Test
Consider ordering a coagulation profile to assess for underlying or developing coagulopathy in the setting of significant PPH.[2] This is mandatory 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
inherited coagulation assays
Test
Testing for inherited coagulopathies can be considered for patients with abnormal coagulation profiles or a family history of hereditary coagulopathy.[2]
Result
identification of an inherited coagulopathy such as von Willebrand disease, hemophilia A, or hemophilia B
diagnostic laparotomy
Test
In patients with refractory PPH, a laparotomy may be performed to further evaluate the pelvic and abdominal organs.[77]
Result
identification of concealed hemorrhage source such as broad ligament and retroperitoneal hematomas
CT abdomen/pelvis
Test
CT with contrast can determine whether ongoing hemorrhage is present and identify the source. Further evaluation with CT may be appropriate in hemodynamically stable patients when conventional medical treatments have failed to control bleeding.[87]
Result
may detect less common underlying cause of PPH, e.g., intra-abdominal hemorrhage; uterine rupture (suggested by presence of gas in the myometrial defect extending from the endometrium to the parametrial tissue, along with hemoperitoneum)
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 facilities to guide transfusion needs and uncover the underlying factors contributing to coagulopathy in patients experiencing PPH.[88][89]
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 hemorrhage. However, their use is limited by the absence of standardized normal reference ranges.[90][91][92][93]
Result
abnormal coagulation index if coagulopathy is present (but standardized 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 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 hemoglobin measurements.[94][95] While the potential benefits of this technology are promising, its long-term efficacy in the context of obstetric care requires further evaluation.
Result
≥1000 mL
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