WHO recommendation on the use of fluid replacement for the treatment of postpartum haemorrhage

WHO recommendation on the use of fluid replacement for the treatment of postpartum haemorrhage

Recommendation

The use of isotonic crystalloids is recommended in preference to the use of colloids for the initial intravenous fluid resuscitation of women with PPH.

(Strong recommendation, low quality evidence)

 

Publication history

First published: September 2012

 

Remarks

None 

 

Background

Postpartum haemorrhage (PPH) is defined as blood loss of 500ml or more within 24 hours after birth. PPH is the primary cause of nearly one-fifth of all maternal deaths globally. Most of these deaths occur during the first 24 hours after birth. The majority could be prevented through the use of prophylactic uterotonics during the third stage of labour, and by timely and appropriate management.

Fluid replacement is an important component of resuscitation for women with PPH, however different types of fluid are often used. It is therefore important to establish what form of fluid is most effective and safe.

 

Methods

The recommendation was developed using standardized operating procedures in accordance with the process described in the “WHO handbook for guideline development”, guided by the GRADE approach.(1, 2) Outcomes used for this recommendation were the prioritized outcomes from the WHO recommendations on prevention and treatment of postpartum haemorrhage (2012).(3)

No RCTs have directly compared the use of colloids with other replacement fluids for the resuscitation of women with PPH. Indirect evidence though was found in two Cochrane reviews of 95 trials (>20,000 participants) which evaluated the use of colloid versus isotonic versus hypertonic crystalloids in the resuscitation of critically ill patients who required volume replacement secondary to trauma, burns, surgery, sepsis, and other critical conditions.(4, 5)  Randomized controlled trials relevant to the key question were screened by review authors, and data on relevant outcomes and comparisons were extracted. Evidence profiles (in the form of GRADE tables) were prepared for comparisons of interest, including the assessment and judgments for each outcome, and the estimated risks. 

WHO convened a Guideline Development Group (GDG) meeting in March 2012. This group of independent experts used the evidence profiles to assess evidence on effects on the pre-specified outcomes. GDG members discussed the balance between desirable and undesirable effects, overall quality of supporting evidence, values and preferences, magnitude of effect, balance of benefits versus disadvantages, resource usage, and feasibility, to finalize the recommendation and remarks.

Further information on procedures for developing this recommendation are available here.

 

Evidence Summary

Indirect evidence though was found in two Cochrane reviews of 95 trials (>20,000 participants) which evaluated the use of colloid versus isotonic versus hypertonic crystalloids in the resuscitation of critically ill patients who required volume replacement secondary to trauma, burns, surgery,

sepsis, and other critical conditions. A total of 85 trials reported data on mortality for the following comparisons. Data about the settings were not provided by the review authors.

Albumin versus control

  • A higher number of deaths was reported in patients with burns who received albumin (RR 2.93; 95% CI 1.28 to 6.72) than in the control group (small sample size).

Colloid versus crystalloid

  • No statistical difference was reported in the incidence of mortality when the following were compared with crystalloids: albumin or plasma protein fraction (23 trials, 7754 patients) (RR 1.01; 95% CI 0.92 to1.10), hydroxyethyl starch (16 trials, 637 patients) (RR 1.05; 95% CI 0.63 to1.75), modified gelatin (11 trials, 506 patients) (RR 0.91; 95% CI 0.49 to 1.72), or dextran (nine trials, 834 patients) (RR 1.24; 95% CI 0.94 to 1.65).

Colloid versus hypertonic crystalloid

  • One trial, which compared albumin or plasma protein fraction versus hypertonic crystalloids, reported one death in the colloid group (RR 7.00; 95% CI 0.39 to 126.92).
  • Two trials which compared hydroxyethyl starch (16 participants) and modified gelatin versus crystalloids (20 participants) reported that there were no deaths

 Colloids in hypertonic crystalloid versus isotonic crystalloid

  • The outcome of death was reported in eight trials (1283 patients) which compared dextran in hypertonic crystalloid versus isotonic crystalloid (RR 0.88; 95% CI 0.74 to 1.05) and in one trial with 14 patients (RR 0.5; 95% CI 0.06 to 4.33)

Further information on evidence supporting this recommendation are available here.

 

Implementation considerations

  • The successful introduction of evidence-based policies related to the prevention and management of PPH into national programmes and health care services depends on well-planned and participatory consensus-driven processes of adaptation and implementation. These processes may include the development or revision ofnational guidelines or protocols based on this recommendation.
  • The recommendation should be adapted into locally-appropriate documents and tools that are able to meet the specific needs of each country and health service. Modifications to the recommendation, where necessary, should be justified in an explicit and transparent manner.
  • An enabling environment should be created for the use of this recommendation (for example, by widening the availability of crystalloid solution), including changes in the behaviour of health care practitioners to enable the use of evidence-based practices.
  • Local professional societies may play important roles in this process and an all-inclusive and participatory process should be encouraged.

 

Research implications

The GDG did not identify any research priorities related to this recommendation.

 

Related links

WHO recommendations for the prevention and treatment of postpartum haemorrhage

Evidence Base and GRADE tables for this recommendation

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

 

Links to the supporting systematic reviews

Alderson P, Bunn F, Li WP, Li LP, M., Roberts I, Schierhout G. Human albumin solution for resuscitation and volume expansion in critically ill patients. Cochrane Database Syst Rev. 2011

Perel P, Roberts I, Pearson M. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. 2011

 

References

1.            World Health Organization. WHO Handbook for Guideline Development (second edition). Geneva: World Health Organization; 2014.

2.            Balshem H, Helfand M, Schünemann HJ, Oxman AD, Kunz R, Brozek J, et al. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol. 2011;64(4):401-6. Epub 2011/01/05. doi: 10.1016/j.jclinepi.2010.07.015. PubMed PMID: 21208779.

3.           World Health Organization. WHO recommendations for the prevention and treatment of postpartum haemorrhage. Geneva: World Health Organization, 2012.

4.            Roberts I, Blackhall K, Alderson P, Bunn F, Schierhout G. Human albumin solution for resuscitation and volume expansion in critically ill patients. Cochrane Database Syst Rev. 2011(11):CD001208. Epub 2011/11/09. doi: 10.1002/14651858.CD001208.pub4. PubMed PMID: 22071799.

5.            Perel P, Roberts I. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. 2011(3):CD000567. Epub 2011/03/16. doi: 10.1002/14651858.CD000567.pub4. PubMed PMID: 21412866.

 

Citation

WHO Reproductive Health Library. WHO recommendation on the use of fluid replacement for the treatment of postpartum haemorrhage (September 2012). The WHO Reproductive Health Library; Geneva: World Health Organization.