Highlight
An individual participant data meta-analysis by WHO evaluated prognostic accuracy of clinical markers for postpartum hemorrhage (PPH) to predict maternal mortality or severe morbidity in over 312,000 women globally.
Lowering the blood loss threshold from 500 mL to 300 mL improved sensitivity for adverse outcomes, albeit with reduced specificity.
Combining measured blood loss thresholds (≥300 mL to <500 mL) with abnormal hemodynamic signs (tachycardia, hypotension, or elevated shock index) further improved predictive accuracy.
This integrated clinical approach supports earlier identification and management of women at risk of life-threatening bleeding complications after childbirth.
Background
Postpartum hemorrhage remains a leading cause of maternal death and severe morbidity worldwide, accounting for approximately 20% of maternal mortality according to WHO data. Despite advances in obstetric care, timely diagnosis of PPH continues to present a challenge, often hampered by the lack of a universally accepted clinical definition or reliable markers signaling excessive blood loss.
Traditionally, a blood loss volume of 500 mL after vaginal delivery has been used as a threshold for diagnosing PPH. However, this volume may not accurately reflect maternal risk, as clinical tolerance to blood loss varies widely. Vital signs such as pulse rate and blood pressure, and derived metrics like the shock index (heart rate divided by systolic blood pressure), reflect hemodynamic instability, potentially serving as adjunctive markers for early detection.
The absence of standardized clinical criteria complicates prompt recognition and management, contributing to preventable adverse maternal outcomes, especially in low-resource settings.
Study Design and Methods
This study is a comprehensive individual participant data (IPD) meta-analysis conducted by the WHO Consortium on Postpartum Hemorrhage Definition, registered under PROSPERO (CRD420251034918). Researchers performed a systematic global search for datasets until November 6, 2024, including published and unpublished studies with at least 200 participants reporting objectively measured blood loss and clinical markers of hemodynamic instability.
In total, 12 eligible datasets comprising 312,151 women were included from an initial 33 identified datasets. The meta-analysis evaluated five clinical markers: measured blood loss, pulse rate, systolic blood pressure, diastolic blood pressure, and shock index. The composite outcome was maternal mortality or severe morbidity, defined as any blood transfusion, surgical intervention, or intensive care admission.
Two-level mixed-effects logistic regression models and a bivariate normal model were utilized to estimate summary prognostic accuracy metrics. Thresholds for these markers were informed by a WHO expert consensus, prioritizing high sensitivity (>80%) to minimize missed cases, with a preference for specificity ≥50% to avoid excessive false positives.
Key Findings
Measured blood loss at the conventional 500 mL threshold had a summary sensitivity of 75.7% (95% CI 60.3–86.4) and specificity of 81.4% (95% CI 70.7–88.8) in predicting adverse maternal outcomes. When the threshold was lowered to 300 mL, sensitivity improved significantly to 83.9% (95% CI 72.8–91.1), but specificity declined to 54.8% (95% CI 38.0–70.5), reflecting more false positives.
Importantly, combining moderate blood loss volumes (100 bpm, systolic blood pressure <100 mm Hg, diastolic blood pressure 1.0—further enhanced prognostic sensitivity to 86.9–87.9% and specificity to 66.6–76.1%. This decision rule balanced early detection with reasonable predictive value.
These findings highlight the limitations of relying solely on blood loss volume and underscore the clinical value of incorporating vital signs indicative of circulatory compromise.
Expert Commentary
This extensive analysis aligns with evolving evidence advocating for dynamic clinical assessment over static blood loss thresholds alone. Dr. A. Metin Gülmezoglu, senior WHO investigator, notes that “measured blood loss under 500 mL, when combined with abnormal hemodynamic signs, can identify women at risk earlier, enabling prompt intervention that may reduce avoidable maternal deaths and complications.” This approach is especially pertinent in resource-limited settings where advanced monitoring technology may be scarce.
Limitations acknowledged include the heterogeneity of included studies with respect to measurement techniques and patient populations. Prospective validation of these combined thresholds in diverse clinical settings would be instrumental before broad implementation.
The shock index, a simple bedside ratio, emerges as a promising standalone and adjunct marker given its sensitivity to early circulatory decompensation.
Conclusion
This WHO individual participant data meta-analysis provides robust evidence that lowering the measured blood loss threshold to 300 mL combined with identification of abnormal vital signs markedly improves prognostic accuracy for identifying women at risk of death or life-threatening complications from postpartum hemorrhage.
Clinical protocols incorporating both quantitative blood loss assessment and hemodynamic evaluation could facilitate earlier PPH diagnosis and targeted treatment, potentially reducing the global burden of maternal morbidity and mortality.
Ongoing efforts should aim to standardize measurement practices and validate these combined criteria across varied obstetric settings, transitioning toward globally harmonized guidelines that optimize maternal outcomes.
References
Gallos I, Williams CR, Price MJ, Tobias A, Devall A, Allotey J, et al. Prognostic accuracy of clinical markers of postpartum bleeding in predicting maternal mortality or severe morbidity: a WHO individual participant data meta-analysis. Lancet. 2025 Oct 4:S0140-6736(25)01639-3. doi: 10.1016/S0140-6736(25)01639-3.
World Health Organization. Maternal mortality fact sheet. Updated 2023.
/Additional literature on shock index and postpartum hemorrhage management from PubMed and WHO guidelines/
