---
title: "Postpartum hemorrhage management and D‑A‑CH algorithm impact: 18‑year single‑center retrospective"
id: "pubmed-42690269"
canonical_url: "https://medichelpline.com/clinical-feed/pubmed-42690269"
content_type: "clinical_feed_article"
specialty: "Critical Care"
source_name: "PubMed / NCBI"
source_url: "https://pubmed.ncbi.nlm.nih.gov/42690269/"
doi: "10.1007/s00101-026-01727-6"
published_at: "2026-09-03T00:00:00.000Z"
evidence_level: "Journal Article"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Postpartum hemorrhage management and D‑A‑CH algorithm impact: 18‑year single‑center retrospective
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/pubmed-42690269
- **Specialty:** [Critical Care](https://medichelpline.com/clinical-feed/critical-care.md)
- **Primary Source:** PubMed / NCBI
- **Source URL:** [Original Journal Publication](https://pubmed.ncbi.nlm.nih.gov/42690269/)
- **DOI:** [10.1007/s00101-026-01727-6](https://doi.org/10.1007%2Fs00101-026-01727-6)
- **Published At:** 2026-09-03T00:00:00.000Z
- **Evidence Rating:** Journal Article
## Executive GIST (TL;DR)
- This single‑center retrospective study reviewed 341 patients treated for **postpartum hemorrhage (PPH)** at University Hospital Ulm from March 2003 to July 2021. - Patients were grouped by local changes in care: before a hemostaseology working group (Group I, n=40), after the working group but before the D‑A‑CH algorithm (Group II, n=103), and after implementation of the **D‑A‑CH algorithm** (Group III, n=198). - Baseline characteristics (age, BMI, parity, mode of delivery, estimated blood loss) did not differ significantly between groups. - Implementation of the hemostaseology working group alone was associated with increased use of **fibrinogen** and **tranexamic acid**, but not with reduced transfusion or shorter stays. - After introduction of the D‑A‑CH algorithm, administration and doses of fibrinogen and tranexamic acid increased significantly compared with earlier periods (fibrinogen median 2.0 g in Group III vs 0.0 g in Groups I and II; tranexamic acid median 1.0 g in Group III vs 0.0–1.0 g in Groups I and II; p < 0.0001 for both). - Use of allogeneic blood products decreased after algorithm implementation (median units of concentrated red cells 2.0 in Group III vs 3.0 in Groups I and II; p = 0.0036). - ICU and total hospital length of stay were significantly shorter after D‑A‑CH implementation (ICU median 3.0 days in Group III with p = 0.0195; hospital stay median 5.0 days in Group III vs 7.0 days in earlier groups; p < 0.0001). - Additional interventions and diagnostics (sulprostone, viscoelastic testing, Bakri balloon tamponade) were used more frequently after the working group and algorithm introduction. - Mortality and acute kidney injury were rare and unchanged across periods; ventilation duration did not differ. - The authors note the retrospective design limits causal inference and call for further study to confirm whether the observed associations reflect true benefit from the D‑A‑CH algorithm implementation.
## Clinical Analysis & Structured Key Points
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Online ahead of print. # Management of postpartum hemorrhage at a level 1 perinatal center : A retrospective analysis over a period of 18 years [Sebastian Hafner](https://pubmed.ncbi.nlm.nih.gov/?term=Hafner+S&cauthor_id=42690269)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42690269/#full-view-affiliation-1 "Department of Anesthesiology and Intensive Care, Sana Klinikum Biberach, Marie-Curie-Str. 4, 88400, Biberach, Germany. sebastian.hafner@uni-ulm.de.")[ 2 ](https://pubmed.ncbi.nlm.nih.gov/42690269/#full-view-affiliation-2 "Faculty of Medicine, Ulm University, Ulm, Germany. sebastian.hafner@uni-ulm.de."), [Martin Wepler](https://pubmed.ncbi.nlm.nih.gov/?term=Wepler+M&cauthor_id=42690269)[ 3 ](https://pubmed.ncbi.nlm.nih.gov/42690269/#full-view-affiliation-3 "Team Anesthesiology South, Pliezhausen, Germany."), [Benjamin Mayer](https://pubmed.ncbi.nlm.nih.gov/?term=Mayer+B&cauthor_id=42690269)[ 4 ](https://pubmed.ncbi.nlm.nih.gov/42690269/#full-view-affiliation-4 "Institute for Epidemiology and Medical Biometry, Ulm University, Ulm, Germany."), [Daniel Haas](https://pubmed.ncbi.nlm.nih.gov/?term=Haas+D&cauthor_id=42690269)[ 5 ](https://pubmed.ncbi.nlm.nih.gov/42690269/#full-view-affiliation-5 "Department of Anesthesiology and Intensive Care, University Hospital Ulm, Ulm, Germany."), [Bettina Jungwirth](https://pubmed.ncbi.nlm.nih.gov/?term=Jungwirth+B&cauthor_id=42690269)[ 5 ](https://pubmed.ncbi.nlm.nih.gov/42690269/#full-view-affiliation-5 "Department of Anesthesiology and Intensive Care, University Hospital Ulm, Ulm, Germany."), [Wolfgang Janni](https://pubmed.ncbi.nlm.nih.gov/?term=Janni+W&cauthor_id=42690269)[ 6 ](https://pubmed.ncbi.nlm.nih.gov/42690269/#full-view-affiliation-6 "Department of Obstetrics and Gynaecology, University Hospital Ulm, Ulm, Germany."), [Beate Hüner](https://pubmed.ncbi.nlm.nih.gov/?term=H%C3%BCner+B&cauthor_id=42690269)[ 6 ](https://pubmed.ncbi.nlm.nih.gov/42690269/#full-view-affiliation-6 "Department of Obstetrics and Gynaecology, University Hospital Ulm, Ulm, Germany."), [Amelie de Gregorio](https://pubmed.ncbi.nlm.nih.gov/?term=de+Gregorio+A&cauthor_id=42690269)[ 7 ](https://pubmed.ncbi.nlm.nih.gov/42690269/#full-view-affiliation-7 "Department of Obstetrics and Gynaecology, SLK-Kliniken Heilbronn, Heilbronn, Germany."), [Nikolaus de Gregorio](https://pubmed.ncbi.nlm.nih.gov/?term=de+Gregorio+N&cauthor_id=42690269)[ 7 ](https://pubmed.ncbi.nlm.nih.gov/42690269/#full-view-affiliation-7 "Department of Obstetrics and Gynaecology, SLK-Kliniken Heilbronn, Heilbronn, Germany."), [Gebhard Fröba](https://pubmed.ncbi.nlm.nih.gov/?term=Fr%C3%B6ba+G&cauthor_id=42690269)[ 8 ](https://pubmed.ncbi.nlm.nih.gov/42690269/#full-view-affiliation-8 "Department of Anesthesiology and Intensive Care, Klinikum Ernst von Bergmann, Potsdam, Germany."), [Benedikt Schick](https://pubmed.ncbi.nlm.nih.gov/?term=Schick+B&cauthor_id=42690269)[ 5 ](https://pubmed.ncbi.nlm.nih.gov/42690269/#full-view-affiliation-5 "Department of Anesthesiology and Intensive Care, University Hospital Ulm, Ulm, Germany.") Affiliations Expand ### Affiliations * 1 Department of Anesthesiology and Intensive Care, Sana Klinikum Biberach, Marie-Curie-Str. 4, 88400, Biberach, Germany. sebastian.hafner@uni-ulm.de. * 2 Faculty of Medicine, Ulm University, Ulm, Germany. sebastian.hafner@uni-ulm.de. * 3 Team Anesthesiology South, Pliezhausen, Germany. * 4 Institute for Epidemiology and Medical Biometry, Ulm University, Ulm, Germany. * 5 Department of Anesthesiology and Intensive Care, University Hospital Ulm, Ulm, Germany. * 6 Department of Obstetrics and Gynaecology, University Hospital Ulm, Ulm, Germany. * 7 Department of Obstetrics and Gynaecology, SLK-Kliniken Heilbronn, Heilbronn, Germany. * 8 Department of Anesthesiology and Intensive Care, Klinikum Ernst von Bergmann, Potsdam, Germany. * PMID: **42690269** * DOI: [ 10.1007/s00101-026-01727-6 ](https://doi.org/10.1007/s00101-026-01727-6) Item in Clipboard # Management of postpartum hemorrhage at a level 1 perinatal center : A retrospective analysis over a period of 18 years Sebastian Hafner et al. Anaesthesiologie. 2026. Show details Display options Display options Format Abstract PubMed PMID Anaesthesiologie Actions * [ Search in PubMed ](https://pubmed.ncbi.nlm.nih.gov/?term=%22Anaesthesiologie%22%5Bjour%5D&sort=date&sort_order=desc) * [ Search in NLM Catalog ](https://www.ncbi.nlm.nih.gov/nlmcatalog?term=%22Anaesthesiologie%22%5BTitle+Abbreviation%5D) * [ Add to Search ](https://pubmed.ncbi.nlm.nih.gov/42690269/) . 2026 Sep 3. doi: 10.1007/s00101-026-01727-6. Online ahead of print. ### Authors [Sebastian Hafner](https://pubmed.ncbi.nlm.nih.gov/?term=Hafner+S&cauthor_id=42690269)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42690269/#short-view-affiliation-1 "Department of Anesthesiology and Intensive Care, Sana Klinikum Biberach, Marie-Curie-Str. 4, 88400, Biberach, Germany. sebastian.hafner@uni-ulm.de.")[ 2 ](https://pubmed.ncbi.nlm.nih.gov/42690269/#short-view-affiliation-2 "Faculty of Medicine, Ulm University, Ulm, Germany. sebastian.hafner@uni-ulm.de."), [Martin Wepler](https://pubmed.ncbi.nlm.nih.gov/?term=Wepler+M&cauthor_id=42690269)[ 3 ](https://pubmed.ncbi.nlm.nih.gov/42690269/#short-view-affiliation-3 "Team Anesthesiology South, Pliezhausen, Germany."), [Benjamin Mayer](https://pubmed.ncbi.nlm.nih.gov/?term=Mayer+B&cauthor_id=42690269)[ 4 ](https://pubmed.ncbi.nlm.nih.gov/42690269/#short-view-affiliation-4 "Institute for Epidemiology and Medical Biometry, Ulm University, Ulm, Germany."), [Daniel Haas](https://pubmed.ncbi.nlm.nih.gov/?term=Haas+D&cauthor_id=42690269)[ 5 ](https://pubmed.ncbi.nlm.nih.gov/42690269/#short-view-affiliation-5 "Department of Anesthesiology and Intensive Care, University Hospital Ulm, Ulm, Germany."), [Bettina Jungwirth](https://pubmed.ncbi.nlm.nih.gov/?term=Jungwirth+B&cauthor_id=42690269)[ 5 ](https://pubmed.ncbi.nlm.nih.gov/42690269/#short-view-affiliation-5 "Department of Anesthesiology and Intensive Care, University Hospital Ulm, Ulm, Germany."), [Wolfgang Janni](https://pubmed.ncbi.nlm.nih.gov/?term=Janni+W&cauthor_id=42690269)[ 6 ](https://pubmed.ncbi.nlm.nih.gov/42690269/#short-view-affiliation-6 "Department of Obstetrics and Gynaecology, University Hospital Ulm, Ulm, Germany."), [Beate Hüner](https://pubmed.ncbi.nlm.nih.gov/?term=H%C3%BCner+B&cauthor_id=42690269)[ 6 ](https://pubmed.ncbi.nlm.nih.gov/42690269/#short-view-affiliation-6 "Department of Obstetrics and Gynaecology, University Hospital Ulm, Ulm, Germany."), [Amelie de Gregorio](https://pubmed.ncbi.nlm.nih.gov/?term=de+Gregorio+A&cauthor_id=42690269)[ 7 ](https://pubmed.ncbi.nlm.nih.gov/42690269/#short-view-affiliation-7 "Department of Obstetrics and Gynaecology, SLK-Kliniken Heilbronn, Heilbronn, Germany."), [Nikolaus de Gregorio](https://pubmed.ncbi.nlm.nih.gov/?term=de+Gregorio+N&cauthor_id=42690269)[ 7 ](https://pubmed.ncbi.nlm.nih.gov/42690269/#short-view-affiliation-7 "Department of Obstetrics and Gynaecology, SLK-Kliniken Heilbronn, Heilbronn, Germany."), [Gebhard Fröba](https://pubmed.ncbi.nlm.nih.gov/?term=Fr%C3%B6ba+G&cauthor_id=42690269)[ 8 ](https://pubmed.ncbi.nlm.nih.gov/42690269/#short-view-affiliation-8 "Department of Anesthesiology and Intensive Care, Klinikum Ernst von Bergmann, Potsdam, Germany."), [Benedikt Schick](https://pubmed.ncbi.nlm.nih.gov/?term=Schick+B&cauthor_id=42690269)[ 5 ](https://pubmed.ncbi.nlm.nih.gov/42690269/#short-view-affiliation-5 "Department of Anesthesiology and Intensive Care, University Hospital Ulm, Ulm, Germany.") ### Affiliations * 1 Department of Anesthesiology and Intensive Care, Sana Klinikum Biberach, Marie-Curie-Str. 4, 88400, Biberach, Germany. sebastian.hafner@uni-ulm.de. * 2 Faculty of Medicine, Ulm University, Ulm, Germany. sebastian.hafner@uni-ulm.de. * 3 Team Anesthesiology South, Pliezhausen, Germany. * 4 Institute for Epidemiology and Medical Biometry, Ulm University, Ulm, Germany. * 5 Department of Anesthesiology and Intensive Care, University Hospital Ulm, Ulm, Germany. * 6 Department of Obstetrics and Gynaecology, University Hospital Ulm, Ulm, Germany. * 7 Department of Obstetrics and Gynaecology, SLK-Kliniken Heilbronn, Heilbronn, Germany. * 8 Department of Anesthesiology and Intensive Care, Klinikum Ernst von Bergmann, Potsdam, Germany. * PMID: **42690269** * DOI: [ 10.1007/s00101-026-01727-6 ](https://doi.org/10.1007/s00101-026-01727-6) Item in Clipboard Cite Display options Display options Format Abstract PubMed PMID ## Abstract in [ English, ](https://pubmed.ncbi.nlm.nih.gov/42690269/#eng-abstract) [ German ](https://pubmed.ncbi.nlm.nih.gov/42690269/#deu-abstract) **Background:** Postpartum hemorrhage (PPH) remains a clinically significant cause of maternal complications and death. Due to the increasing incidence, international recommendations have been implemented, such as the D‑A-CH algorithm, an interdisciplinary and transnational treatment algorithm for Germany, Austria and Switzerland. This study aims to evaluate both the impact of implementing a hemostaseology working group and adopting the internationally recognized D‑A-CH algorithm on the clinical management of PPH in a university hospital. **Methods:** In this single-center retrospective observational study, patient records were reviewed from all patients treated for PPH between March 2003 and July 2021 at the University Hospital Ulm, Germany (n = 341). Data were divided into three groups: (I) patients treated before the implementation of a working group for hemostaseology (n = 40), (II) patients treated after the implementation of a working group for hemostaseology and before the clinical application of the D‑A-CH-algorithm (n = 103) and (III) patients treated after the clinical application of the D‑A-CH algorithm (n = 198). **Results:** After the implementation of the D‑A-CH-algorithm, a significantly higher amount of fibrinogen (2.0 g, interquartile range, IQR, 0.0-3.0 g in group III vs. 0.0 g, IQR 0.0-2.0 g in group II and 0.0 g, IQR 0.0-0.0 g in group I ; p < 0.0001) and tranexamic acid (1.0 g, IQR 1.0-1.5 g in group III vs. 1.0 g, IQR 0.0-1.0 g in group II and 0.0 g, IQR 0.0-0.0 g in group I; p < 0.0001) was administered. Additionally, transfusion of allogeneic blood products (units of concentrated red cells: 2.0, IQR 0.0-4.0 in group III vs. 3.0, IQR 2.0-5.0 in group II and 3.0, IQR 0.0-7.8 in group I; p = 0.0036), intensive care unit (ICU) stay (3.0 days, IQR 2.0-4.0 days in group III vs. 3.0 days, IQR 2.0-5.0 days in group II and 3.0 days, IQR 2.0-4.3 days in group I; p = 0.0195) and hospital stay (5.0 days, IQR 3.0-7.0 days in group III vs. 7.0 days, IQR 5.0-9.0 days in group II and 7.0 days, IQR 5.0-9.0 days in group I; p < 0.0001) was significantly reduced. Implementation of a hemostaseology working group alone was only associated with increased fibrinogen and tranexamic acid administration. **Conclusion:** In this retrospective study, application of the D‑A-CH algorithm was associated with improved targeted hemostatic therapy and reduced transfusion requirements as well as shorter ICU and hospital stays, whereas implementation of a hemostaseology working group alone was only associated with increased fibrinogen and tranexamic acid administration. Due to the retrospective design of the study and inherent limitations therein, we were unable to draw a causative effect relationship. Nonetheless, our results warrant further study. **Zusammenfassung:** HINTERGRUND: Die postpartale Hämorrhagie (PPH) zählt weltweit zu den häufigsten vermeidbaren Ursachen maternaler Morbidität und Mortalität. Neben Blutungskontrolle und uterotonen Maßnahmen ist eine zielgerichtete Gerinnungstherapie essenziell. Zur Standardisierung der Behandlung wurde der interdisziplinäre D‑A-CH-Algorithmus entwickelt. Bereits zuvor war am Universitätsklinikum Ulm eine hämostaseologische Arbeitsgruppe etabliert worden. Ziel dieser Studie war die Untersuchung des Einflusses beider Maßnahmen auf das Management der PPH. **Methoden:** In dieser retrospektiven monozentrischen Beobachtungsstudie wurden 341 Patientinnen analysiert, die zwischen 2003 und 2021 aufgrund einer PPH am Universitätsklinikum Ulm behandelt wurden. Eingeschlossen wurden Frauen mit einem Blutverlust von mindestens 500 ml nach vaginaler Geburt bzw. 1000 ml nach Sectio caesarea. Entsprechend der Entwicklung der Versorgungsstrukturen erfolgte die Einteilung in drei Gruppen: vor Einführung der hämostaseologischen Arbeitsgruppe (Gruppe I, n = 40), nach Einführung der Arbeitsgruppe, jedoch vor Implementierung des D‑A-CH-Algorithmus (Gruppe II, n = 103), sowie nach Implementierung des Algorithmus (Gruppe III, n = 198). Primäre Zielgrößen waren die Anwendung von Fibrinogenkonzentrat, Tranexamsäure und allogenen Blutprodukten; sekundäre Zielgrößen die Aufenthaltsdauer auf Intensivstation und im Krankenhaus. **Ergebnisse:** Die Gruppen unterschieden sich nicht hinsichtlich Alter, Body-Mass-Index, Parität, Geburtsmodus oder geschätztem Blutverlust. Nach Implementierung des D‑A-CH-Algorithmus stieg die Verwendung bzw. die Dosierung von Fibrinogenkonzentrat und Tranexamsäure signifikant an. Gleichzeitig wurde der Bedarf an allogenen Blutprodukten wie Erythrozytenkonzentraten und Frischplasmen signifikant reduziert. Diese Effekte blieben auch nach Adjustierung für relevante Einflussfaktoren bestehen. Nach Einführung der hämostaseologischen Arbeitsgruppe und des D‑A-CH-Algorithmus wurden Sulproston sowie viskoelastische Gerinnungsdiagnostik signifikant häufiger eingesetzt; nach Implementierung des Algorithmus kam zudem die Bakri-Ballon-Tamponade häufiger zur Anwendung. Die veränderte Therapie war mit einer signifikanten Verkürzung der Aufenthaltsdauer auf Intensivstation und im Krankenhaus assoziiert. Die Beatmungsdauer unterschied sich nicht zwischen den Gruppen. Mortalität und akutes Nierenversagen waren selten und blieben unverändert. Während bereits die Einführung der hämostaseologischen Arbeitsgruppe zu einer häufigeren Anwendung von Fibrinogen und Tranexamsäure führte, zeigten sich ein geringerer Blutproduktverbrauch und kürzere statio
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