Haemostatic management in postpartum haemorrhage. Nationwide survey in Germany

In order to ensure evidence-based haemostatic management of postpartum haemorrhage (PPH, blood loss > 500 ml) consistent with guidelines appropriate structural conditions must be fulfilled regardless of different levels (1-3) in perinatal care. The aim of the survey was to identify differences in haemostatic management in PPH under consideration of the different levels of perinatal care in Germany. An electronic questionnaire assessing the structural and therapeutic preconditions for haemostatic management was sent to 533 anaesthesiology departments serving obstetric units. A total of 156 (29 %) questionnaires returned from hospitals of all levels were analysed. PPH occur in all and increase with higher level hospitals (level 1 < 5 PPH/year vs. 3 > 30 PPH/year). The percentage of PPH requiring red blood cell (RBC) transfusion amounts to < 25 % (all levels). A bleeding history (35 %, all levels), laboratory coagulation tests (29 %, all levels) as well as viscoelastic point-of-care coagulation tests (42 %, mainly level 3) are limited in their availability. Blood loss is usually estimated (99 %, all levels), not measured. Tranexamic acid (> 80 %, all levels), fibrinogen (> 60 %, all levels) and fresh frozen plasma (FFP) (30 %, level 2a) are first line therapeutics. In level 2b and 3 FFP is a second line therapeutic. RBC transfusion is indicated at haemoglobin < 5-7 g/dl (57-69 %, all levels), while 15-29 % in level 3 did not base their decision to transfuse RBC on haemoglobin only. Guideline-consistent haemostatic management of PPH is provided in almost all hospitals independent of the perinatal care level. Deviances from guidelines (measuring blood loss, bleeding history of the patient) affect all levels of perinatal care in Germany.