Clinical Opinion ajog.

org

Postpartum hemorrhage: new insights for

definition and diagnosis
A. Borovac-Pinheiro, PhD; R. C. Pacagnella, PhD; J. G. Cecatti, PhD; S. Miller, PhD; A. M. El Ayadi, ScD, MPH;
J. P. Souza, PhD; J. Durocher, MA; P. D. Blumenthal, MD, MPH; B. Winikoff, MD, MPH

blood lost after birth. In 1990, a tech-

The current definition of is inadequate for early recognition of this important cause of nical working group of the World
maternal death that is responsible for >80,000 deaths worldwide in 2015. A stronger Health Organization (WHO) defined
definition of postpartum hemorrhage should include both blood loss and clinical signs of PPH as blood loss of 500 mL from the
cardiovascular changes after delivery, which would help providers to identify postpartum genital tract after vaginal delivery.8
hemorrhage more promptly and accurately. Along with the amount of blood loss, clinical Despite WHO’s statement in the same
signs, and specifically the shock index (heart rate divided by systolic blood pressure) report that this blood loss threshold
appear to aid in more accurate diagnosis of postpartum hemorrhage. might not be clinically significant given
the lack of supporting evidence, 500 mL
Key words: postpartum hemorrhage, definition, clinical sign, shock index was selected as the volume of blood loss
for PPH diagnosis based on the
customarily used cutoff and what was
n 2015 there were >80,000 maternal
I deaths caused by obstetric hemor-
rhage worldwide.1 Although there has
deaths in countries with a high socio-
demographic index and 45.7% in
countries with a low sociodemographic
considered as normal postpartum blood
loss.8
Studies preceding the 1990 WHO
been a reduction in the absolute number index.1,2 Most deaths caused by hemor- definition of PPH that measured blood
of maternal deaths caused by hemor- rhage occur in the postpartum period in loss with the gold standard spectro-
rhage over the last 25 years, it remains both high-income countries (49.1%) metric and labelled erythrocyte methods
the leading direct obstetric cause of and low-/middle-income countries found an average blood loss of 300e550
maternal death.1,2 Recent estimates (73%).2 Among women with post- mL for vaginal delivery and 500e1100
suggest that 29.3% of maternal deaths partum hemorrhage (PPH), 17% will mL for cesarean delivery.9-14 However,
and 26.7% of severe adverse maternal have either a maternal near miss or the sample sizes in these studies were
outcomes globally are due to hemor- death; however, geographic disparities in very small (n <123) and limited to
rhage.1-3 Great variation exists region- the incidence of severe maternal out- hospital deliveries.
ally; hemorrhage accounts for 9.3% of comes after PPH suggest the need to The most recent WHO definitions of
improve quality of care.4 PPH (2012) reflect the 1990 definition.
From the Department of Obstetrics and Prevalence estimates for PPH vary in For vaginal births, PPH is defined as
Gynecology, School of Medical Sciences, the literature from 1e10% of all de- blood loss >500 mL,15,16 and severe PPH
University of Campinas, Campinas, Brazil (Drs liveries. Risk factors for PPH include a is defined as loss of >1000 mL. In cases
Borovac-Pinheiro, Pacagnella, and Cecatti); the variety of maternal factors (ie, advanced of cesarean birth, the standard for PPH is
Department of Obstetrics, Gynecology, and
Reproductive Sciences, University of California,
maternal age, nulliparity, anemia, previ- raised to 1000 mL in some guidelines.17
San Francisco, CA (Dr Miller and Ms El Ayadi); ous cesarean delivery, fibroid tumors), Other protocols use different defini-
the Department of Social Medicine, School of pregnancy complications (ie, placenta tions (Table 1).17-23 Nevertheless, recent
Medicine of Ribeirão Preto, University of São previa or abruption, multiple gestation, and more robust studies confirm the
Paulo, Ribeirao Preto, Brazil (Dr Souza); Gynuity polyhydramnios, amnionitis, hyperten- great variability in measured blood loss
Health Projects, New York, NY (Ms Durocher,
and Dr Winikoff); Stanford University School of
sive disorders of pregnancy), and delivery that range from <150 mL to almost 700
Medicine, Department of Obstetrics and characteristics (ie, episiotomy, retained mL for uncomplicated vaginal de-
Gynecology, Division of Family Planning placenta, laceration, uterine rupture, high livery,24-26 which challenges the clinical
Services and Research, Stanford University, neonatal weight).5,6 However, the ability relevance of a particular blood loss
Stanford, CA (Dr Blumenthal). to predict PPH from antepartum and threshold.
Received Nov. 26, 2017; revised March 23, intrapartum risk factors is very low.7 Furthermore, blood loss thresholds
2018; accepted April 9, 2018.
Therefore, efforts to reduce adverse may not adequately represent risk of
The authors report no conflict of interest. maternal outcomes must focus on the poor outcome. The different PPH defi-
Corresponding author: R.C. Pacagnella, PhD. early recognition and treatment of PPH. nitions by delivery method are even
rodolfopacagnella@gmail.com
more confusing: why would a blood loss
0002-9378/$36.00 Definition and diagnosis of 500 mL represent a risk for women
ª 2018 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.ajog.2018.04.013 The most commonly accepted defini- after vaginal delivery but not for a ce-
tion of PPH is based on the amount of sarean delivery? In addition to the wide

162 American Journal of Obstetrics & Gynecology AUGUST 2018

ajog.org
range of normal postpartum blood loss
values, the arbitrary cutoff lacks clinical
accuracy.
Many women will lose >500 mL
without any clinical consequence, and
some will bleed less and will still be at
risk of adverse outcome.27,28 A woman’s
baseline health may be an important
determinant of her ability to tolerate
blood loss of any volume. For instance,
most healthy nonanemic women will
not exhibit signs and symptoms of
hemodynamic instability until blood
loss reaches 1000 mL.13,14,24,29 In a
healthy population, this quantity of
blood loss will even be considered as
physiologic and may not trigger any
intervention. In contrast, for women
whose organ systems are compromised
by a comorbidity, earlier intervention
may be required at a lower blood loss
volume to avoid poor end organ
perfusion.
No high-quality evidence exists to
support the current definition of PPH
based on the amount of blood loss.
Furthermore, reliable measurement of
blood loss presents a significant chal-
lenge for blood loss thresholdebased
diagnosis. The WHO recommends
visual estimation of blood loss as the
standard for blood loss measurement;30
yet, visual estimation is known to be
highly unreliable.31,32 Visual estimation
of postpartum blood loss compared
with spectrophotometry underestimates
blood loss by 33e50%,17,31,32 thus
possibly delaying both recognition and
treatment.
A variety of blood loss measurement
techniques have been used in clinical
practice to improve measurement
validity, such as the under buttocks
drape with a graduated/calibrated
pouch.9,17,33-35 Other efforts to improve
validity include low-cost strategies such
as absorbent delivery mats or soaking of
common household cloths.36,37 When
blood loss is recorded by direct
measurement techniques, there is a
higher mean blood loss (difference, 58.6
mL) and almost twice as many women
are identified with PPH than by indirect
measurement.38 However, there is no
evaluation method that is used broadly
for precise blood loss measurement.
In an attempt to improve the quanti-
fication of blood loss after delivery, a
movement has begun in high resource
settings to measure blood loss compre-
hensively after delivery with the use of a
drape and by weighing all compresses
and sponges, not only after vaginal de-
liveries but also after cesarean deliveries.
Although this practice results in
improved accuracy of blood loss mea-
surement, it is limited by the utility of
blood loss volume in the diagnosis of
PPH; women experience PPH differen-
tially at similar levels of blood loss, with
some women losing large amounts of
blood without entering into a life-
threatening situation.
Furthermore, a more accurate assess-
ment of blood loss alone has not been
shown to improve the provision of PPH
care. A large randomized cluster trial
conducted in 78 hospitals across Europe
that compared visual estimation of blood
loss after delivery to objective assessment
with the use of a calibrated receptacle
revealed that rates of severe PPH and the
provision of additional interventions did
not differ substantially between the 2
methods of blood loss assessment.39
There is also recognition of the
importance of the consideration of
clinical status; in fact, most guidelines
include the recognition of changes in
clinical status as part of the classification
of PPH severity. Measureable compo-
nents include heart rate, arterial blood
pressure, respiratory rate, and even the
speed of blood flow. Together with the
amount of blood loss, clinical conditions
could offer a more reliable picture of
what is happening within the cardio-
vascular system of the bleeding woman.
Many clinical guidelines include vital
signs in the definitions and diagnosis of
PPH16,17 without specifying which clin-
ical signs are important. Most guidelines
refer to hemodynamic instability or ev-
idence of clinical shock as the triggers for
intervention.16
The WHO working group that estab-
lished the 500-mL cut-off for defining
PPH also concurred that PPH diagnosis
is a clinical decision; thus, clinicians may
decide to initiate therapeutic action at a
lower level of blood loss than 500 mL.8 In
another technical report by WHO in the
AUGUST 2018 American Journal of Obstetrics & Gynecology
Clinical Opinion
mid-1990s, it was further clarified that
“the 500 mL limit as defined by WHO
should be considered an alert line; the
action line is then reached when vital
functions of the woman are endan-
gered.”40 Although giving the clinician
considerable freedom to manage each
individual patient’s course, these pro-
posals regarding how the 500-mL
threshold could be used in practice
have generated uncertainty about when
to intervene. An imprecise diagnostic
threshold makes guideline and protocol
development difficult.
An additional challenge is when to
consider a postpartum woman as
showing “evidence of clinical shock” or
“hemodynamic instability.” Some au-
thors have proposed classification
models to trigger treatment for PPH
(Table 2).28,29,41 However, these systems
mainly rely on estimated blood loss and
therefore have the same problems as the
definitions of WHO described earlier.
In the nonobstetric population, the
definition of hypovolemic shock is under
discussion. Studies have found that
higher blood pressure than once previ-
ously thought can still be associated with
adverse outcomes in trauma patients.
Changes in clinical signs during bleeding
do not correlate with the amount of
blood lost as proposed by the traditional
classifications of hypovolemic shock for
trauma populations.42 Some authors
have proposed that hypotension should
be redefined with a higher cut-off of
blood pressure.43-45
In postpartum women, consideration
of clinical signs for triggering PPH
treatment should rest on a clear under-
standing of the cardiovascular system
during pregnancy. Changes in the car-
diovascular system may be protective for
most women with hemorrhage because
the adaptation of the cardiovascular
system helps to compensate for the loss
of blood after birth.
Briefly, cardiovascular changes begin
around the sixth week of pregnancy,
produce an increase in blood volume of
45% (1200e1600 mL), and reach a
maximum volume of 4700e5200 mL
at approximately 32 weeks gesta-
tion.46,47 Cardiac output increases by
approximately 50% during pregnancy
163
Clinical Opinion ajog.org

TABLE 1
Summary of blood loss thresholds and vital sign changes for diagnosis of postpartum hemorrhage according to
international clinical guidelines
Guideline
International Federation
of Gynecology and
Obstetrics, 201215
American College of
Obstetricians and
Gynecologists, 201720
Royal College of
Obstetricians and
Gynaecologists, 201621
Society of Obstetricians
and Gynaecologists
of Canada, 201022
Royal Australian and
New Zealand College
of Obstetricians and
Gynaecologists, 201623
PPH, postpartum hemorrhage.
Borovac-Pinheiro. PPH: new insights for definition and diagnosis. Am J Obstet Gynecol 2018.
Vaginal/cesarean delivery
Loss >500 mL/>1000 mL
Cumulative blood loss 1000 mL,
regardless of route of delivery
Estimated blood loss of 500e1000
mL (minor PPH) and >1000 mL
(major PPH) with no clinical signs of
shock
Loss >500 mL/>1000 mL
Estimated blood loss 500 mL; severe
PPH after blood loss of 1000 mL
Vital signs
For clinical purposes, any blood loss
that has the potential to produce
hemodynamic instability should be
considered a postpartum
hemorrhage.
Signs or symptoms of hypovolemia;
important to recognize that the signs
or symptoms of considerable blood
loss often do not present or do not
present until blood loss is
substantial
Pulse and blood pressure normal
until blood loss exceeds 1000 mL;
tachycardia, tachypnea slight fall in
systolic blood pressure with blood
loss of 1000e1500 mL; >1500 mL
systolic blood pressure <80 mm Hg,
worsening tachycardia, tachypnea,
and altered mental state
Any blood loss that has the potential
to produce hemodynamic instability
should be considered PPH.
Clinical signs of shock or
tachycardia, which includes an
accurate appraisal of blood loss
(both concealed and revealed),
should prompt a thorough
assessment of the mother.
Comments
Clinical estimates of blood loss are
often inaccurate.
Excess of 500 mL after vaginal
delivery is an alert; when
postpartum bleeding exceeds
expected volumes (500 mL in a
vaginal delivery or 1,00 mL in a
cesarean delivery), a careful and
thorough evaluation should be
undertaken.
A blood loss of >40% of total blood
volume (approximately 2800 mL) is
generally regarded as “life-
threatening.”
The amount of blood loss required to
cause hemodynamic instability will
depend on the preexisting condition
of the woman.
It is important to consider both the
patient’s previous hemoglobin level
and her total blood volume for the
assessment of the severity of PPH.

that ranges from 4.6 L/min to 8.7 L/min
on average and reaches its peak between
25 and 35 weeks of gestation, after
which it remains stable until delivery.
The heart rate increases from the fifth
week of gestation and is up to 15e20
beats/min higher at approximately 32
weeks gestation. Both systolic and dia-
stolic blood pressures fall from 12e14
weeks gestation onwards, which is
caused by the reduction in peripheral
resistance because of placental circula-
tion bypass. From the week 24 of
gestation until birth, there is a gradual
return of blood pressure to prepreg-
nancy levels or higher because of
increased blood volume.47,48
During labor, uterine contractions,
pain, anxiety, and the Valsalva maneuver
promote an increase in sympathetic
tone, which raises heart rate and blood
pressure. In addition, there is an increase
in preload, which changes the stroke
volume and results in a 30% higher
cardiac output. Immediately after
childbirth, there is a rise of 60e80% in
cardiac output because of the transfer of
blood from the uterus into the circula-
tory system and because of the increase
in venous flow. These changes diminish
after the first 10 minutes, approaching
normal approximately 1 hour after de-
livery. The cardiac output decreases by
one-third within 2 weeks after delivery
and is expected to return to nonpregnant
values after 24 weeks.46,47
In healthy pregnant and postpartum
women, physiologic compensatory
mechanisms prevent changes in vital
signs until a large amount of blood has
been lost (usually >1000 mL).17,47
Hence, changes in vital signs that result
from hemorrhage appear late in the
process and may not lead to early iden-
tification of PPH.28
In the obstetric population, there is
substantial variability in the changes in
clinical signs that are associated with
blood loss, which makes it difficult to
establish cutoff points to trigger clinical
interventions.49 Moreover, because
traditional vital signs change late and are
less reliable as triggers for clinical ac-
tions, other indicators could help to
characterize maternal hypovolemia
caused by bleeding, which include the
requirement for blood transfusion, the

164 American Journal of Obstetrics & Gynecology AUGUST 2018

ajog.org Clinical Opinion

TABLE 2
Maternal hemorrhage classification systems
Acute blood Blood pressure,
Hemorrhage class loss, mL Lost, % mm Hg Clinical signs
41
Benedetti
1 900 15 — —
2 1200e1500 20e25 — —
3 1800e2100 30e35 — —
4 2400 40 — —
29
Bonnar
500e1000 Normal Palpitations, dizziness, tachycardia
1000e15000 Slightly low Weakness, sweating, tachycardia
1500e2000 70e80 Restlessness, pallor, oliguria
2000e3000 50e70 Collapse, air hunger, anuria
28
Coker and Oliver
0 <500 <10 — None
1 500e1000 15 — Minimal
2 1200e1500 20e25 — Decreased urine output,
increased pulse rate, increased postural
hypotension, narrow pulse pressure
3 1800e2100 30e35 — Hypotension, tachycardia,
cold clammy skin, tachypnea
4 >2400 >40 — Profound shock
Borovac-Pinheiro. PPH: new insights for definition and diagnosis. Am J Obstet Gynecol 2018.

rate of blood loss, and the decrease in
hematocrit value. However, none of
these has improved the identification of
PPH consistently or helped trigger
action.28 Blood transfusion varies
according to supply, the judgment of in-
dividual clinicians and patient accep-
tance, other parameters that include the
rate of blood loss and hematocrit value
may not represent the woman’s current
clinical status because they are often
determined retrospectively, can be influ-
enced by other factors, and may not be
available in all settings.50,51
New insights: the shock index
Although the use of conventional indi-
vidual vital signs (pulse and systolic
blood pressure) may lack accuracy in the
assessment of hypotension, a simple
combination of them may transform
apparently routine clinical parameters
into a more accurate indicator of hypo-
volemia, called the shock index (SI). The
SI is calculated by dividing heart rate by
systolic blood pressure and may improve
the predictive capability of individual
clinical signs, which aids early identifi-
cation of women at risk of hypovolemia
as the result of obstetric causes.49
The SI was first used in 1967 to iden-
tify hypovolemic shock among patients
after acute gastrointestinal hemor-
rhage.52-54 There is an inverse relation-
ship between the SI and left ventricular
function that is related to the severity of
reduction in systemic blood flow and
oxygen transport.54,55 In the trauma
population, the SI has been shown to be
a good predictor of death.56-58 In ob-
stetric populations, the SI was first used
to identify the severity of blood loss in
ectopic pregnancy.59
Studies found the SI to be a valid in-
dicator of blood loss in the first trimester
of pregnancy for patients with abdom-
inal pain and a better indicator of
ruptured ectopic pregnancy and hemo-
peritoneum than other clinical signs.59-63
However, blood loss that occurs in the
first trimester of pregnancy may trigger a
different cardiovascular response than
blood loss in the postpartum period.
Although this clinical sign may be valid
for this population, its reliability for
postpartum blood loss is yet to be
determined.
Although the SI is not a new indicator
that represents severity of condition
among trauma patients, its use in the
obstetric population is recent. This may
be due to the cardiovascular physiologic
changes during pregnancy, which reduce
the accuracy of clinical signs to identify
bleeding during the pregnancy-
puerperal period. Renewed attention to
the role of vital signs in the evaluation of
PPH followed the more recent publica-
tion of studies that relate SI to severe
hemorrhagic conditions.
Recent studies have shown a direct
relationship between elevated SI and the
need for blood transfusion in term
obstetric populations,64,65 which indicates
that the SI might be a useful tool for the

AUGUST 2018 American Journal of Obstetrics & Gynecology 165

Clinical Opinion
identification of severe PPH. Le Bas
et al65 also found that an SI >0.9 indi-
cated the need for massive transfusion in
PPH patients. Previous research has
identified the normal range of SI to be
0.5e0.7 in the nonpregnant population
and 0.66e0.75 in early postpartum
women.65,66 A recent study established
standard reference values for the SI for
low-risk pregnancy. The authors found
that the mean SI values ranged from
0.75e0.83 in pregnancy across all
gestational ages.
The mean values decreased towards
the end of gestation; for women at >37
weeks gestation, the mean SI value was
0.79.67 For term pregnancies, an SI of 0.9
represents the 82th percentile. For
postpartum women, the SI might be
slightly different, ranging from
0.52e0.89, and may be influenced by the
use of epidural anesthesia and ergome-
trine in the third stage of labor.66 This
fact indicates that almost 20% of women
without cardiovascular problems at term
or in the postpartum period would have
an SI of >0.9. Therefore, although 1
isolated assessment of the SI might be
important, changes in the SI during
labor and the postpartum period (ie, a
trend in an upward direction) might be a
better indicator of acute cardiovascular
alterations or an imminent crisis. Such
changes in the SI can be noted even
before significant changes in blood
pressure and heart rate occur.
In a retrospective analysis of 958
women who experienced hypovolemic
shock because of obstetric hemorrhage
of all causes, the authors found the SI to
be a better predictor of death and severe
adverse maternal outcomes (death or
severe morbidity) than other vital
signs,68 and only 6.3% of those women
had an SI <0.9 at the time of study
admission.
An additional retrospective observa-
tional study of women with PPH showed
that, among the vital signs assessed, the
SI had best accuracy for adverse
maternal outcomes. The cut-off of 0.9
for SI for maternal death, severe end-
organ failure maternal morbidity,
intensive care unit admission, and other
adverse maternal outcomes showed high
sensitivity and negative predictive value;
166 American Journal of Obstetrics & Gynecology AUGUST 2018
however, the clinical utility of this
threshold is limited by its low specificity.
SI values above the 1.7 threshold had
high specificity and negative predictive
value, with better clinical applicability.69
Considering the changes in cardio-
vascular response at the end of preg-
nancy, the SI appears to be useful in
helping to detect shock. The focal point
is that there may be clinical signs that
could help the diagnose PPH and SI
appears to be 1 of the best hints. It is
simple to calculate for most facilities and
providers, and its use could be refined to
make it even simpler. For instance, if
using an SI >0.9, providers in the field
who might have difficulty with division
calculations could be told that, if the
heart rate is higher than systolic blood
pressure (thus giving a number >0.9),
the postpartum woman probably needs
referral or intervention.70 However,
further evaluation of the SI is necessary
to determine its utility as an early indi-
cator of compromise among the obstet-
ric population.
Comment
The current definition of PPH, which
relies solely on the amount of blood lost,
may not fit clinical needs. We agree with
the recent discussion about the need to
redefine PPH.17,71 Neither the visual
estimation of blood loss nor the use of
single vital signs has proved helpful in
our quest to recognize PPH early and to
treat it promptly. Finding a strategy that
will trigger earlier actions among women
who are at highest risk of adverse
outcome remains crucial to the
improvement of maternal outcomes. In
settings with few PPH treatment options
and many home deliveries, diagnosis and
treatment/referral must be even earlier
than in hospital settings to improve
outcomes. Earlier action for women who
are most at risk of adverse outcome is
necessary; however, a balance is also
required to avoid unnecessarily over-
burdening healthcare systems.
The criteria for recognizing PPH
should be simple and easy to use in
everyday clinical practice in all settings
and should include clinical findings to
facilitate prompt diagnosis and treat-
ment and the early identification of
ajog.org
women who are likely to experience
shock. Preliminary evidence suggests
that the SI may be 1 such indicator
because it may have better predictive
ability than other vital signs, may show
changes in the maternal cardiovascular
system, and may be simple to use.
Nevertheless, the predictive ability of the
SI and other clinical indicators to trigger
timely treatment of PPH remains un-
known but is deserving of rigorous
prospective assessment.
Nevertheless, the predictive ability of
the SI and other clinical indicators to
trigger timely treatment of PPH remains
unknown but is deserving of rigorous
prospective assessment, as well as other
clinical aspects of postpartum women
that make the clinical judgment of PPH
possible. Studies on the rate of blood
loss, the percentage of blood volume lost
during childbirth, prospective studies on
clinical signs its relation to organ
perfusion, and the physiology of post-
partum bleeding, which includes
dynamic effect of interventions on the
cardiovascular system, may help us to
diagnose PPH more accurately. -
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