What's New in Postpartum Haemorrhage (PPH) - 2025 Updates

Major Development: WHO Consolidated Guidelines (October 2025)

1. Revised Definition of PPH

Blood loss ≥ 1,000 mL accompanied by signs of hypovolemia (rather than the older ≥500 mL cutoff)

• The conventional 500 mL threshold has only 75.7% sensitivity for predicting mortality or severe morbidity
• Sensitivity improves to 87-88% when combining blood loss of 300-450 mL plus any abnormal haemodynamic sign (pulse >100, SBP <100, DBP <60, or shock index >1.0)
• This supports a combined clinical marker approach over volume alone for earlier diagnosis

2. New Guidance on Tranexamic Acid (TXA) - KEY UPDATE

• Rec. 14 (NEW): TXA is NOT recommended for prevention of PPH at vaginal birth
• Rec. 15 (NEW): TXA is NOT recommended for prevention of PPH at caesarean birth

3. Uterotonic Rankings - Updated Cochrane Network Meta-Analysis (2025)

• Combination agents outperform oxytocin alone, though with more side effects
• WHO still recommends oxytocin 10 IU (IM/IV) as the first-line standard (Rec. 24, revalidated), but combination therapy is preferred where feasible
• Carbetocin (heat-stable formulation) continues to be supported especially in low-resource settings without cold chains

4. Updated Diagnostic Approach

• Universal objective blood loss measurement (calibrated drapes, weighing) is now recommended - not visual estimation
• Standardized risk assessment tool before and after every delivery
• Early action at combined threshold of ≥300 mL + any haemodynamic sign, rather than waiting for 500 mL

5. ACOG Update: Nonsurgical Hemorrhage-Control Devices (October 2025)

• Uterine balloon tamponade remains a core second-line intervention
• Newer devices (e.g. Jada system - intrauterine vacuum-induced hemorrhage control) are now addressed with revised guidance
• Devices should be used as part of a structured bundle, not in isolation

6. Structured Treatment Bundle (Revalidated & Reinforced)

1. Objective assessment of blood loss
2. Rapid uterine massage
3. Uterotonic agent (oxytocin IV/IM)
4. Tranexamic acid 1g IV (for treatment, within 3 hours of delivery)
5. IV fluids
6. Genital tract examination
7. Clear escalation to second-line (balloon tamponade → surgical repair → embolization → hysterectomy)

7. Aetiology Confirmed by Global Data

• Uterine atony: 70.6% of cases
• Genital tract trauma: 16.9%
• Retained placenta: 16.4%
• Coagulation disorders: less common

8. Health Systems & Global Implementation

• Supply chain strengthening for heat-stable uterotonics in low-resource settings
• Training modules and simulation-based emergency drills for frontline workers
• National implementation guides, developed with UNFPA
• Equity lens - most of the 70,000 annual deaths occur in low- and middle-income countries

Summary Table: What Changed in 2025

• WHO Consolidated PPH Guidelines 2025, executive summary
• Gallos et al., Lancet 2025 - prognostic markers meta-analysis (PMID: 41056961)
• Gallos et al., Cochrane 2025 - uterotonic network meta-analysis (PMID: 40237648)
• ACOG Clinical Practice Update 2025 on nonsurgical hemorrhage-control devices

Massive Transfusion Protocol (MTP) - Complete Overview

What Is It?

• Rosen's Emergency Medicine, p. 2429
• Henry's Clinical Diagnosis, p. 881

Definition of Massive Transfusion (Trigger Volume)

Activation Criteria - The ABC Score

• Blood loss > 150 mL/min
• Blood loss > 50% of blood volume within 3 hours
• Anticipated need for ≥3 units in 1 hour

The Core Concept: Damage Control Resuscitation (DCR)

1. Massive hemorrhage depletes all blood components - red cells, plasma, platelets, and clotting factors
2. Replacing only red cells (old strategy) worsens the lethal triad: coagulopathy + hypothermia + acidosis
3. Reconstituting whole blood by giving components in a ratio approximating whole blood is the solution

The 1:1:1 Ratio - The Standard of Care

• Rosen's Emergency Medicine, p. 2430
• Bailey & Love's Surgery, 28th Ed.

MTP Protocol - Step-by-Step (Denver Health/Schwartz's Surgery Model)

Phase 1 - Trigger & Activate

• SBP ≤70 OR (SBP 71-90 AND HR ≥108) PLUS any of: penetrating torso injury / major pelvic fracture / FAST+ in >1 region
• ACTIVATE MTP - call blood bank, notify OR, anaesthesia, lab
• Give CaCl₂ 1g IV immediately (combat citrate-induced hypocalcaemia)

Phase 2 - Empiric (Pre-Lab) Transfusion

Phase 3 - Goal-Directed (TEG/ROTEM-Guided)

• PT/PTT > 1.5x control → FFP 2 units
• Platelets < 50,000/µL → 1 unit apheresis platelets
• Fibrinogen < 100 mg/dL → 10 units pooled cryoprecipitate

The "Lethal Triad" MTP Targets

         COAGULOPATHY
              △
             /|\
            / | \
           /  |  \
    ACIDOSIS──────HYPOTHERMIA

• Clotting factors/FFP → treat coagulopathy
• Warming all blood products → prevent/treat hypothermia
• Restoring perfusion (not crystalloid overload) → treat acidosis

Blood Products in MTP - At a Glance

Whole Blood - The Emerging Trend

• Provides all components in physiological ratios in a single unit
• Reduces logistical burden in pre-hospital care
• Reduces donor exposures
• ACS TQIP now includes guidance on LTOWB in MTP frameworks

When to Stop (MTP Termination Criteria)

• Bleeding is controlled surgically
• Haemodynamics are stable
• Labs normalize (Hb, PT/INR, fibrinogen, platelets in acceptable range)
• Clinical decision by senior physician

Complications of Massive Transfusion

Key Evidence Base

• The PROPPR trial (Holcomb et al.): 1:1:1 reduces exsanguination deaths at 24h vs 2:1:1
• Williams et al., Cochrane 2025 - transfusion of blood products for PPH management (PMID: 39911088)
• ACS TQIP MTP Guidelines - standardization across trauma systems, 2025
• TEG/ROTEM-guided resuscitation associated with lower mortality vs conventional coag parameters in trauma (Rosen's EM, p. 2430)

What's New in Endometriosis - 2024/2025 Updates

Quick Pathogenesis Recap

1. BIGGEST CHANGE: End of the "Laparoscopy First" Dogma

Old Standard

New Approach (ACOG 2025, ESHRE 2022, NICE 2024, Canadian Guideline 2024)

• Characteristic symptoms (dysmenorrhoea, deep dyspareunia, dyschezia, chronic pelvic pain, infertility)
• Physical examination (fixed retroverted uterus, tender uterosacral ligaments, deeply infiltrating nodules in POD)
• Imaging (TVUS, MRI) - especially for endometriomas and DIE

Laparoscopy is still needed when: imaging is negative but symptoms are convincing, surgical intervention is planned, or cancer needs to be excluded.

2. Imaging Advances - "Imaging First"

Transvaginal Ultrasound (TVUS) - Now Standardized

• The IDEA (International Deep Endometriosis Analysis) group in 2024 expanded its consensus guidelines to include routine evaluation of the parametrium for lateral compartment disease
• Standardized TVUS protocols now reliably detect DIE, endometriomas, and bowel involvement
• Pelveoneurosonography - a new technique that visualises sacral nerve roots and plexus, structures implicated in chronic pelvic pain that were previously invisible on standard imaging

MRI - Harmonised Protocols

• MRI protocols are being standardised internationally for greater consistency in preoperative assessment
• MRI detects haemosiderin deposits in abdominal organs suggesting DIE; role is strongest for complex or extragenital disease

Molecular Imaging - DETECT Study (Oxford)

• Non-invasive, functional imaging of active endometriotic lesions
• Detection of early-stage and superficial peritoneal disease (the one type current imaging still misses)

New ACR Appropriateness Criteria (2024)

3. Biomarkers - Approaching Clinical Readiness

Why Biomarkers Matter

Current Reality Check (ESHRE 2025)

4. New Drugs - Oral GnRH Antagonists

Traditional Medical Options (Still Used)

NEW: Oral GnRH Antagonists - Second-Line Standard

• Immediate suppression (no initial "flare" of estrogen/LH seen with agonists)
• Oral formulation (vs injectable agonists)
• Rapid reversibility on stopping
• Titratable dosing - can balance symptom control vs. side effects (hot flushes, bone loss)
• All used with add-back hormone therapy to mitigate hypoestrogenic side effects and bone loss

5. Aromatase Inhibitors - Confirmed Role in Refractory Cases

• Medical castration failures
• Postmenopausal patients with recurrent disease
• Deep infiltrating endometriosis refractory to standard therapy

6. Artificial Intelligence in Diagnosis

• Triage role - identifying patients who need specialist imaging or referral
• Adolescent and fertility patient pathways - accelerating diagnosis in high-risk groups
• MRI pattern recognition - deep learning models being trained on pelvic MRI datasets
• TVS analysis - though highly operator-dependent images make AI development harder

7. Endometriosis and Fertility - New Evidence

• Endometriosis independently increases risks of placenta praevia, preterm birth, and SGA neonates
• IVF outcomes are affected - but less than previously thought when confounders are separated

Endometrioma Surgery Before IVF

• Ovarian cystectomy (not drainage) still preferred for definitive treatment
• Preoperative oocyte cryopreservation should be considered for bilateral disease

8. New Classification Needs

9. Psychosocial Recognition - A Formal Update

10. Global Prevalence - Updated Estimates

Summary Table: Key 2024-2025 Changes