title: Postpartum hemorrhage: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians (CNGOF): in collaboration with the French Society of Anesthesiology and Intensive Care (SFAR).
abstract: Postpartum haemorrhage (PPH) is defined as blood loss ≥500mL after delivery and severe PPH as blood loss ≥1000mL, regardless of the route of delivery (professional consensus). The preventive administration of uterotonic agents just after delivery is effective in reducing the incidence of PPH and its systematic use is recommended, regardless of the route of delivery (Grade A). Oxytocin is the first-line prophylactic drug, regardless of the route of delivery (Grade A); a slowly dose of 5 or 10 IU can be administered (Grade A) either IV or IM (professional consensus). After vaginal delivery, routine cord drainage (Grade B), controlled cord traction (Grade A), uterine massage (Grade A), and routine bladder voiding (professional consensus) are not systematically recommended for PPH prevention. After caesarean delivery, placental delivery by controlled cord traction is recommended (grade B). The routine use of a collector bag to assess postpartum blood loss at vaginal delivery is not systematically recommended (Grade B), since the incidence of severe PPH is not affected by this intervention. In cases of overt PPH after vaginal delivery, placement of a blood collection bag is recommended (professional consensus). The initial treatment of PPH consists in a manual uterine examination, together with antibiotic prophylaxis, careful visual assessment of the lower genital tract, a uterine massage, and the administration of 5-10 IU oxytocin injected slowly IV or IM, followed by a maintenance infusion not to exceed a cumulative dose of 40IU (professional consensus). If oxytocin fails to control the bleeding, the administration of sulprostone is recommended within 30minutes of the PPH diagnosis (Grade C). Intrauterine balloon tamponade can be performed if sulprostone fails and before recourse to either surgery or interventional radiology (professional consensus). Fluid resuscitation is recommended for PPH persistent after first line uterotonics, or if clinical signs of severity (Grade B). The objective of RBC transfusion is to maintain a haemoglobin concentration (Hb) >8g/dL. During active haemorrhaging, it is desirable to maintain a fibrinogen level ≥2g/L (professional consensus). RBC, fibrinogen and fresh frozen plasma (FFP) may be administered without awaiting laboratory results (professional consensus). Tranexamic acid may be used at a dose of 1 g, renewable once if ineffective the first time in the treatment of PPH when bleeding persists after sulprostone administration (professional consensus), even though its clinical value has not yet been demonstrated in obstetric settings. It is recommended to prevent and treat hypothermia in women with PPH by warming infusion solutions and blood products and by active skin warming (Grade C). Oxygen administration is recommended in women with severe PPH (professional consensus). If PPH is not controlled by pharmacological treatments and possibly intra-uterine balloon, invasive treatments by arterial embolization or surgery are recommended (Grade C). No technique for conservative surgery is favoured over any other (professional consensus). Hospital-to-hospital transfer of a woman with a PPH for embolization is possible once hemoperitoneum is ruled out and if the patient's hemodynamic condition so allows (professional consensus).
authors.affiliation: Service de Gynécologie-Obstétrique, CHU Bordeaux, 33076 Bordeaux, France. Electronic address: loicsentilhes@hotmail.com.
authors.forename: Loïc
authors.initials: L
authors.lastname: Sentilhes
authors.affiliation: Service de Gynécologie-Obstétrique, Hôpital Paule de Viguier, CHU Toulouse, 31059 Toulouse, France; UMR 1027 Inserm Université Toulouse III « Epidémiologie Périnatale et handicap de l'enfant, Santé des adolescents », 31000 Toulouse, France.
authors.forename: Christophe
authors.initials: C
authors.lastname: Vayssière
authors.affiliation: INSERM U1153, Equipe de recherche en Epidémiologie Obstétricale, Périnatale et Pédiatrique (EPOPé), Paris, France.
authors.forename: Catherine
authors.initials: C
authors.lastname: Deneux-Tharaux
authors.affiliation: Département Anesthésie-Douleur, Groupe Hospitalo-Universitaire Caremeau, Place du Pr Debré, 30029 Nîmes Cedex 09, France; EA2992 - Faculté de médecine Montpellier-Nîmes, 186, chemin du carreau-de-Lanes, 30029 Nîmes Cedex 2, France.
authors.forename: Antoine Guy
authors.initials: AG
authors.lastname: Aya
authors.affiliation: CHU de Toulouse, Pole d'anesthésie Réanimation, Hôpital Paule de Viguier, Toulouse F-31059, France.
authors.forename: Françoise
authors.initials: F
authors.lastname: Bayoumeu
authors.affiliation: INSERM U1153, Equipe de recherche en Epidémiologie Obstétricale, Périnatale et Pédiatrique (EPOPé), Paris, France; Département d'anesthésie-réanimation, Hôpital Cochin, APHP, université Paris-Descartes, Paris, France.
authors.forename: Marie-Pierre
authors.initials: MP
authors.lastname: Bonnet
authors.affiliation: Etablissement Français du Sang, 20, Avenue du Stade de France, 93218 La Plaine Saint-Denis Cedex, France.
authors.forename: Rachid
authors.initials: R
authors.lastname: Djoudi
authors.affiliation: Service de Gynécologie-Obstétrique, CHU Caen et UFR de Médecine Caen, 14033 Caen, France.
authors.forename: Patricia
authors.initials: P
authors.lastname: Dolley
authors.affiliation: Service de Gynécologie-Obstétrique, CHU Caen et UFR de Médecine Caen, 14033 Caen, France; UFR de Médecine Caen, 14033 Caen, France.
authors.forename: Michel
authors.initials: M
authors.lastname: Dreyfus
authors.affiliation: Association d'usagers, Collectif interassociatif autour de la naissance (CIANE), Paris, France.
authors.forename: Chantal
authors.initials: C
authors.lastname: Ducroux-Schouwey
authors.affiliation: Réseau périnatal Aurore - Hôpital de la Croix Rousse, université Lyon 1, Lyon, France; EA 4129, laboratoire « Santé, individu, société », faculté de médecine Laennec, 69372 Lyon, France.
authors.forename: Corinne
authors.initials: C
authors.lastname: Dupont
authors.affiliation: Etablissement Français du Sang Ile de France, site de l'Hôpital Européen Georges-Pompidou, APHP, Paris, France.
authors.forename: Anne
authors.initials: A
authors.lastname: François
authors.affiliation: Service de Gynécologie-Obstétrique, CHU Estaing, 63003 Clermont-Ferrand, France; R2D2-EA7281, Université d'Auvergne, 63000 Clermont-Ferrand, France.
authors.forename: Denis
authors.initials: D
authors.lastname: Gallot
authors.affiliation: Service de Gynécologie-Obstétrique, CHU Marseille, Hôpital Nord, AP-HM, 13015 Marseille, France.
authors.forename: Jean-Baptiste
authors.initials: JB
authors.lastname: Haumonté
authors.affiliation: Réseau périnatal Aurore - Hôpital de la Croix Rousse, université Lyon 1, Lyon, France; INSERM U846, Stem Cell and Brain Research Institute, Lyon, France.
authors.forename: Cyril
authors.initials: C
authors.lastname: Huissoud
authors.affiliation: Service de Gynécologie-Obstétrique, Hôpital Louis-Mourier, AP-HP, 92701 Colombes, France.
authors.forename: Gilles
authors.initials: G
authors.lastname: Kayem
authors.affiliation: Service d'Anesthésie, CHU Louis-Mourier, AP-HP/Université Paris-7, 178, rue des Renouilliers, 92700 Colombes, France; Université Paris-Diderot, Sorbonne Paris Cité, EA recherche clinique coordonnée ville-hôpital, méthodologies et société (REMES), 75010 Paris, France.
authors.forename: Hawa
authors.initials: H
authors.lastname: Keita
authors.affiliation: Département de Gynécologie-Obstétrique, Hôpital de Hautepierre, Avenue Molière, 67098 Strasbourg, France.
authors.forename: Bruno
authors.initials: B
authors.lastname: Langer
authors.affiliation: CHU de Toulouse, Pole d'anesthésie Réanimation, Hôpital Paule de Viguier, Toulouse F-31059, France.
authors.forename: Alexandre
authors.initials: A
authors.lastname: Mignon
authors.affiliation: Service d'Obstétrique et de Médecine fœtale, Pôle de Gynécologie-Obstétrique, CHU de Nancy, Université de Lorraine, 10 rue Heydenreich, 54000 Nancy, France.
authors.forename: Olivier
authors.initials: O
authors.lastname: Morel
authors.affiliation: Inserm, UMR1027, Toulouse F-31073, France; Université de Toulouse III, UMR1027, Toulouse F-31073, France; CHU Toulouse, Pole de Gynécologie Obstétrique, Hôpital Paule de Viguier, Toulouse F-31059, France.
authors.forename: Olivier
authors.initials: O
authors.lastname: Parant
authors.affiliation: Département de Radiologie, CHU Caen, 14033 Caen, France.
authors.forename: Jean-Pierre
authors.initials: JP
authors.lastname: Pelage
authors.affiliation: Association d'usagers, Collectif interassociatif autour de la naissance (CIANE), Paris, France.
authors.forename: Emmanuelle
authors.initials: E
authors.lastname: Phan
authors.affiliation: Département d'Anesthésie Réanimation SMUR, Hôpital Lariboisière, Assistance Publique Hôpitaux de Paris, France.
authors.forename: Mathias
authors.initials: M
authors.lastname: Rossignol
authors.affiliation: Collège National des Sages-Femmes, France; DHU Risques et Grossesse, 53 avenue de l'observatoire, Paris, France.
authors.forename: Véronique
authors.initials: V
authors.lastname: Tessier
authors.affiliation: Société Française d'Anesthésie et de Réanimation, France; Département d'Anesthésie, Hôpital Antoine Béclère, APHP, Clamart, France; Faculté de Médecine de K. Bicêtre, Université Paris-Sud, France.
authors.forename: Frédéric J
authors.initials: FJ
authors.lastname: Mercier
authors.affiliation: INSERM U1153, Equipe de recherche en Epidémiologie Obstétricale, Périnatale et Pédiatrique (EPOPé), Paris, France; DHU Risques et Grossesse, 53 avenue de l'observatoire, Paris, France; Maternité Port-Royal, Université Paris Descartes, Groupe hospitalier Cochin Broca Hôtel-Dieu, Assistance Publique-Hôpitaux de Paris, Paris, France.
authors.forename: François
authors.initials: F
authors.lastname: Goffinet
mesh_terms: D036861:Delivery, Obstetric / Q000009:adverse effects* / Q000379:methods; D005260:Female; D006801:Humans; D010120:Oxytocics / Q000008:administration & dosage / Q000627:therapeutic use*; D010121:Oxytocin / Q000008:administration & dosage / Q000627:therapeutic use*; D006473:Postpartum Hemorrhage / Q000188:drug therapy / Q000517:prevention & control / Q000628:therapy*; D011247:Pregnancy
chemical_list: D010120:Oxytocics; D010121:Oxytocin
keywords: Oxytocin; Peripartum hysterectomy; Placenta accreta; Postpartum hemorrhage; Transfusion