Safety and Effectiveness of Uterine Gauze Packing for Refractory Postpartum Haemorrhage: A Systematic Review and Meta-Analysis.

Abstract

The role of uterine gauze packing in treating refractory postpartum haemorrhage (PPH) is uncertain given limited evidence of benefit and possible harms. To evaluate the safety and effectiveness of uterine packing using plain gauze or gauze impregnated with haemostatic agent(s) for treating refractory PPH. We searched MEDLINE, Embase, Emcare, Web of Science, CINAHL and CENTRAL from inception through March 2025. Randomised controlled trials (RCTs) and non-randomised controlled studies of intervention (NRSIs) evaluating uterine packing using plain gauze or gauze impregnated with haemostatic agents, compared with usual care or other interventions, for women with refractory PPH. We included one RCT (204 women) and six NRSIs (814 women). We presented findings from the RCT in a forest plot and conducted random-effects meta-analyses for NRSIs. Three comparisons had data: plain gauze versus balloon tamponade; gauze impregnated with haemostatic agents versus balloon tamponade; and plain gauze versus uterine artery ligation/embolisation. From the RCT, uterine packing with plain gauze may not reduce the need for additional surgical/radiological intervention (relative risk (RR) 1.29, 95% CI 0.50-3.32) or blood transfusion (RR 0.97, 95% CI 0.67-1.41; low certainty evidence). Moderate-certainty evidence indicates that for women with refractory PPH, uterine packing with plain gauze probably increases postpartum anaemia (< 11 g/dL) (RR 1.27, 95% CI 1.07-1.51) and maternal fever > 38°C (RR 2.40, 95% CI 1.21-4.76), compared to balloon tamponade. From NRSIs, evidence is very uncertain about the effects of uterine packing with plain gauze or gauze impregnated with haemostatic agents on all outcomes (very low certainty evidence). There are no clear benefits of uterine packing with plain gauze or gauze impregnated with haemostatic agents for treating refractory PPH, and the risk of postpartum anaemia and maternal fever is probably increased compared to standard care. Prospective well-controlled trials are needed to evaluate the effects of uterine packing and its role in treating refractory PPH.