| Intervention Outcome | Study Design Quality and Number of Studies (N Total With PPH) | Study Limitationsa | Consistency | Directness | Precision | Reporting Bias | Finding Strength of Evidence Grade |
|---|---|---|---|---|---|---|---|
| Pharmacologic | |||||||
| Tranexamic acid All harms | RCT-1 good (114)69 | Low | Unknown | Direct | Imprecise | Undetected | Insufficient SOE due to small sample size, but serious harms did not differ between groups and mild, transient harms occurred more often in TXA group |
| Sulprostone All harms | Case series-1 poor (1370)70 | High | Unknown | Direct | Precise | NA | Insufficient SOE as only one study considered poor quality for harms reporting |
| Methylergonovine maleate Acute coronary syndrome and myocardial infarction | Retrospective cohort study-1 good (139,617)60 | Low | Unknown | Direct | Precise | NA | Low SOE for lack of association of methylergonovine maleate with acute coronary syndrome and myocardial infarction; no significant difference in the incidence of these conditions in the exposed and non-exposed groups |
| Carboprost tromethamine All harms | Case series-1 poor (237) 71 | High | Unknown | Direct | Imprecise | NA | Insufficient SOE as only one study considered poor quality for harms reporting |
| rFVIIa Thromboembolic events | Case-control-1 fair (12)74 Retrospective cohort-1 fair (48)73 Retrospective case series- 1 good, 2 poor (unclear due to overlap of 2 studies)75, 76, 80 | High | Consistent | Direct | Imprecise | NA | Insufficient SOE; 4 of 5 studies (unclear overlap in 2 studies) reported thromboembolic events (pulmonary embolus, deep vein thrombosis, myocardial infarction) but sample sizes were small and study limitations are high |
| Other Medical Interventions | |||||||
| Transfusion for supportive management of PPH All harms | Retrospective cohort-2 poor (1574)83, 84 Pre-post-1 poor (93)86 Case series-1 good, 3poor (1152)61, 63, 65, 81 | High | Inconsistent | Direct | Precise | NA | Insufficient SOE due to inconsistency, study limitations |
| Procedures | |||||||
| Uterine balloon tamponade All harms | Pre-post-1 poor (43)87 Case series-2 poor (102)80, 90 | High | Consistent | Direct | Imprecise | NA | Insufficient SOE due to small studies with high limitations |
| Embolization | |||||||
| Infertility | Retrospective cohort-2 poor (152)92-95 Case-control-1 poor (53)91 Case series-2 poor (169) 97, 98 | High | Inconsistent | Direct | Imprecise | NA | Low SOE for negative effect of embolization on future fertility. Infertility rate among women who had embolization in these studies was greater than that of the overall population rate (range 0-43%), but few women (n = 300) available for long-term followup; high study limitations and inconsistency among studies |
| Spontaneous abortion in subsequent pregnancy | Retrospective cohort-2 poor (152)92-95 Case-control-1 poor (53)91 Case series-1 good, 3 poor (421) 97, 98, 105, 108 | High | Consistent | Direct | Imprecise | NA | Low SOE for lack of association between embolization and spontaneous abortion in subsequent pregnancy in the small number of women followed-up; rates ranged from 5-21.4%, which is comparable to estimates in the general population |
| Menstrual changes | Retrospective cohort-2 poor (152)92-95 Case-control-1 poor (53)91 Case series-1 good, 4 poor (709) 97, 98, 101, 105, 108 | High | Consistent | Direct | Imprecise | NA | Low SOE for an association between embolization and menstrual changes. Rates of menstrual change (heavier, lighter, or irregular menses and amenorrhea) ranged from 2 to 22% |
| Hematoma | Retrospective cohort-2 poor (152)92-95 Case-control-1 poor (53)91 Case series-1 good, 2 poor (544)101, 105, 106 | High | Consistent | Direct | Precise | NA | Low SOE for association between embolization and hematoma; rates ranged from 1.7-6% |
| Surgical Interventions | |||||||
| Uterine compression sutures | |||||||
| Preterm birth | Case-control-2 good (105 with PPH and sutures)62, 66 | Medium | Consistent | Direct | Imprecise | NA | Low SOE for no effect of sutures on preterm birth; in 2 studies; preterm births did not differ between women in case and control groups |
| Ligation Surgical injury | Retrospective cohort study-1 poor (48)96 Case series-1 poor (539-not clear how many had ligation)111 | High | Consistent | Direct | Imprecise | NA | Insufficient due to high study limitations and imprecision; injuries (inadvertent ligation of the ureters and secondary hysterectomy disunion with sepsis) related to ligation reported in both studies |
| Hysterectomy | |||||||
| Bladder and ureter lesions | Prospective cohort-1 poor (108)109 Case series-5 poor (2784)45, 64, 110, 115, 116 | High | Consistent | Direct | Precise | NA | Low SOE for association of hysterectomy and operative organ damage; rates of bladder and ureter lesions ranged from 6%-12% and 0.4%-41%, respectively |
| Reoperation | Prospective cohort-1 poor (108)109 Case series-3 poor, 1 good (574)110, 115-117 | High | Consistent | Direct | Precise | NA | Low SOE for association between hysterectomy and reoperation. Rates of reoperation ranged from 1.8-29% |
Note: Study limitations are rated on a low to high scale. Low limitations=more rigorously designed study.
Abbreviations: LOS = length of stay; NA = not applicable; PPH = postpartum hemorrhage; RCT = randomized controlled trial; SOE = strength of the evidence; TXA = tranexamic acid
From: Discussion
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