Management of secondary postpartum haemorrhage: A systematic review

Secondary postpartum haemorrhage is a significant cause of postnatal morbidity and admission to hospital. It can be managed medically, surgically or with interventional radiological techniques, however, there is limited evidence to inform the most appropriate use of these treatments. This review aimed to summarise the existing evidence and evaluate the effectiveness and safety of the management options available for secondary postpartum haemorrhage. MEDLINE, EMBASE, CENTRAL, SCOPUS, Clinicaltrials.gov and ICTRP were searched from conception to August 2021. Eligible studies described the management of participants with secondary postpartum haemorrhage occurring between 24 h and 12 weeks after a pregnancy of at least 20 weeks gestation. All treatment interventions were eligible. Outcomes included reduction of bleeding, hospital admissions, re-presentations to hospital, secondary surgical procedures, blood transfusions, adverse effects of treatment, surgical complications, hysterectomy, ICU admissions, severe morbidity and mortality. The protocol for this review was registered with PROSPERO (ID: CRD42021274146). Eleven studies, describing 834 participants, were eligible for inclusion. Five studies reported outcomes of a single intervention and six studies reported outcomes of more than one treatment modality. Assessed interventions included medical management, surgical procedures, and radiological techniques. Resolution of bleeding was seen in 8.2-84.6 % of participants following medical management, 89.3-100 % following surgical management and 87.5-100 % post transcatheter arterial embolisation. When considering only studies published in the last 30 years, these results are 71.9-73.7 %, 89.3-92.0 % and 87.5-100 % respectively. All included studies were small and retrospective observational in design with poor methodological quality leading to a serious or critical risk of bias. This review has highlighted the deficiencies in evidence for the management of secondary PPH. Future, well designed, prospective studies are needed to provide guidance to clinicians managing this condition.