Pan American Health Organization · 1st edition, 2024 · 164 pages
Clinical protocols for hypertensive disorders, thromboembolism, amniotic fluid embolism, COVID-19, influenza, sepsis, CPR, and postpartum hemorrhage in pregnancy for clinicians in the Americas
- Issuer
- Pan American Health Organization
- Edition
- 1st edition, 2024
- Audience
- Obstetricians, midwives, anesthesiologists, intensivists, emergency physicians, and public health professionals managing obstetric emergencies in hospitals and referral centers across the Americas
- Evidence
- GRADE-rated recommendations for new chapters (pulmonary thromboembolism, amniotic fluid embolism, COVID-19, influenza, maternal sepsis); updated chapters based on 2019-2022 international guidelines from ACOG, ISSHP, FIGO, WHO, NICE, SOGC, ESC, AHA, ERC with consensus expert adaptation to resource-variable settings
- Reviewed
- 17 Oct 2026 · GMJ
What this guideline says
GMJ summary
This Pan American Health Organization manual provides comprehensive, GRADE-based clinical protocols for eight major obstetric emergencies that account for a substantial proportion of maternal deaths in Latin America and the Caribbean. The guidelines integrate the latest international evidence (ACOG, ISSHP, FIGO, WHO, NICE) into actionable algorithms using cognitive aids and structured response strategies.
Each emergency is addressed through a standardized approach: recognition criteria with specific vital sign thresholds, diagnostic pathways adapted to available resources (low/medium/high-complexity institutions), time-critical interventions with exact drug doses, and interdisciplinary management protocols. The manual emphasizes early warning systems, simulation-based team training, and the CRISIS-6 and SEPSIS-6 mnemonics for hypertensive and septic emergencies.
The document updates previous CLAP/WR protocols and adds new chapters on pulmonary thromboembolism (YEARS algorithm adapted to pregnancy), amniotic fluid embolism, COVID-19 (including oxygen escalation and ECMO indications), influenza, and maternal sepsis. All recommendations are contextualized for resource-variable settings across the Americas, with institutional checklists to guide protocol adaptation.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Hypertensive crisis (SBP ≥160 mmHg and/or DBP ≥110 mmHg) requires antihypertensive treatment within 15 minutes: nifedipine 10-20 mg PO, labetalol 20-80 mg IV, or hydralazine 5-10 mg IV, targeting SBP 130-150 mmHg and DBP 80-100 mmHg within one hour
- Magnesium sulfate for severe preeclampsia/eclampsia: loading dose 4-6 g IV over 10-15 minutes, then maintenance 1-2 g/hour; toxicity monitored by patellar reflexes, respiratory rate <12/min, and diuresis <30 mL/hour
- Pulmonary thromboembolism treatment: enoxaparin 1 mg/kg every 12 hours or dalteparin 200 units/kg once daily; discontinue 24 hours before planned delivery; epidural catheter not removed within 12 hours of last injection
- COVID-19 in pregnancy: oxygen supplementation if SatO₂ <95%; dexamethasone 6 mg daily for 10 days if requiring supplemental oxygen; high-flow nasal cannula monitored with Rox index (failure predicted if <2.85 at 2 hours or <3.47 at 6 hours)
- Maternal sepsis: within first hour collect cultures, measure lactate, start antibiotics (Gram-negative + Gram-positive coverage), give 30 mL/kg crystalloids, and initiate norepinephrine 0.05-1 mcg/kg/min if MBP <65 mmHg; Sepsis in Obstetrics Score ≥8 predicts ICU admission
- Cardiopulmonary resuscitation in pregnancy ≥20 weeks: manual left uterine displacement or 15° left lateral tilt; if no return of spontaneous circulation after 4 minutes of high-quality CPR, perform perimortem cesarean (resuscitative hysterotomy) within 5 minutes of arrest
- Postpartum hemorrhage requiring massive transfusion: tranexamic acid 1 g IV over 10 minutes within 3 hours of delivery; use viscoelastic testing (TEG/ROTEM) when available to guide blood component therapy; fibrinogen <200 mg/dL requires cryoprecipitate
- Early warning systems: Obstetric Early Warning Score triggers urgent medical review if total score 4-5 or any single parameter scores 3; emergency response if score ≥6 with continuous monitoring and critical care competencies
First-line therapy recommendations for acute treatment of hypertensive crisis in pregnant women
Table extracted from the guideline
| Drug | Initial dose | Subsequent doses | Maximum | Check BP after |
|---|---|---|---|---|
| Nifedipine PO | 10 mg | 20 mg if BP remains high | 60 mg in 1 hour | 20 minutes |
| Labetalol IV | 20 mg over 2 min | 40 mg, then 80 mg | 220 mg total | 10 minutes |
| Hydralazine IV | 5-10 mg over 2 min | 10 mg | 30 mg total | 20 minutes |
Source: Pan American Health Organization, Recommendations for the Management of Major Obstetric Emergencies. Reproduced in summary form.
What changed in this edition
Versus the previous edition
- Added six new chapters: pulmonary thromboembolism, amniotic fluid embolism, COVID-19, influenza, maternal sepsis, and early warning systems
- Updated hypertensive disorders chapter with 2020-2022 guidelines from ACOG, ISSHP, FIGO, NICE, SOGC, and ESC; removed massive proteinuria (>5 g) from severity criteria
- Introduced CRISIS-6 mnemonic and intervention package for hypertensive emergencies with color-coded blood pressure recognition chart (144/86 = hypertension; 150/112 = crisis)
- Updated cardiopulmonary resuscitation protocols with 2021 European Resuscitation Council and 2020 American Heart Association guidelines
- Added YEARS algorithm adapted to pregnancy for pulmonary thromboembolism diagnosis using adjusted D-dimer thresholds by trimester
From the guideline
Verbatim
“If there is doubt, there is no doubt: when pulmonary thromboembolism is suspected, anticoagulant management should be initiated while the necessary paraclinical tests are performed, to confirm or rule out the diagnosis, unless absolutely contraindicated.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As a clinician who has worked with WHO on health systems strengthening in the South Caucasus, I see this PAHO manual as directly applicable to Georgian maternity hospitals confronting the dual burden of traditional obstetric emergencies and new threats like COVID-19 co-infections. The most critical recommendation for our context is the institutional resource checklist stratifying diagnostic algorithms by complexity level—this pragmatic approach acknowledges that not every facility has CT angiography or high-flow oxygen, yet still provides evidence-based pathways. Georgian obstetricians should particularly note the lowered threshold for magnesium sulfate in preeclampsia (now indicated for all severe cases, not just imminent eclampsia) and the 15-minute window for treating hypertensive crisis, which will require pre-positioned medication kits and team drills. One implementation challenge for Georgia will be ensuring 24/7 availability of low-molecular-weight heparin for thromboembolism treatment in rural hospitals, where medication supply chains remain variable despite recent pharmaceutical sector reforms; the national essential medicines list should be reviewed to guarantee this coverage. The manual's emphasis on simulation training and early warning scores aligns well with the quality improvement initiatives already underway in Georgian perinatal centers following Resolution 3280, providing ready-made protocols to operationalize those regulations.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 17 Oct 2026
Applicability
Georgia and the South Caucasus
These protocols address the leading causes of maternal mortality in Georgia and the South Caucasus, where hypertensive disorders and hemorrhage remain significant contributors to maternal deaths despite recent improvements. The guideline’s three-tier institutional resource checklist (low/medium/high complexity) is particularly relevant for Georgia’s mixed health system, where Tbilisi referral hospitals have CT and echocardiography while rural facilities may lack rapid D-dimer testing. The emphasis on early warning systems aligns with Georgia’s 2018 Resolution 3280 mandating Obstetric Early Warning Scores in all maternity facilities. National adaptation would need to consider Georgia’s universal health coverage context (state programme since 2013 covers delivery care), the referral structure between rayon hospitals and republican centers, availability of low-molecular-weight heparin in the essential medicines list, and integration with existing protocols for managing preeclampsia and postpartum hemorrhage in the national maternal mortality reduction roadmap.
Questions this guideline answers
Quick answers
When should I start antihypertensive treatment in a pregnant woman with high blood pressure?
Start treatment immediately (within 15 minutes) when blood pressure reaches crisis level: systolic ≥160 mmHg and/or diastolic ≥110 mmHg. Use first-line drugs (nifedipine 10 mg PO, labetalol 20 mg IV, or hydralazine 5-10 mg IV) and recheck blood pressure at specified intervals (10-20 minutes). Target is systolic 130-150 mmHg and diastolic 80-100 mmHg within the first hour. This applies regardless of whether the patient has chronic hypertension, gestational hypertension, or preeclampsia.
How do I diagnose pulmonary embolism in pregnancy when D-dimer is often elevated?
Use the pregnancy-adapted YEARS algorithm: assess three criteria (clinical signs of deep vein thrombosis, hemoptysis, pulmonary embolism most likely diagnosis). If zero YEARS criteria, pulmonary embolism is excluded if D-dimer <1000 ng/mL. If one or more criteria, exclude if D-dimer <500 ng/mL. If D-dimer exceeds these thresholds or criteria are present, perform compression ultrasound of lower limbs; if positive for DVT, treat without further imaging. If negative, proceed to chest X-ray to decide between V/Q scan (if normal X-ray) or CT pulmonary angiography (if abnormal X-ray).
When should I perform perimortem cesarean delivery during maternal cardiac arrest?
If the pregnant woman is ≥20 weeks gestation (uterus at or above umbilicus) and there is no return of spontaneous circulation after 4 minutes of high-quality CPR, immediately prepare for resuscitative hysterotomy. The goal is delivery within 5 minutes of cardiac arrest onset to improve maternal resuscitation (by relieving aortocaval compression) and give the fetus the best chance of intact survival. Do not delay for transport to the operating room, antibiotics, or formal skin preparation—use splash prep only. This is primarily a maternal resuscitation intervention.
What oxygen saturation target should I aim for in a pregnant patient with COVID-19 pneumonia?
Target arterial oxygen saturation (SatO₂) ≥95% in pregnant patients, which is higher than the ≥90-94% target for non-pregnant adults. This reflects pregnancy physiology: lower functional residual capacity, increased oxygen consumption, and the need to maintain adequate fetoplacental oxygenation. Start supplemental oxygen if SatO₂ drops below 95%. Escalate through low-flow devices (nasal cannula, simple mask, non-rebreather mask) to high-flow nasal cannula if needed, monitoring the Rox index to predict high-flow cannula failure and guide timing of intubation.
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- Implementation guidance on transitioning to midwifery models of care
- Issuer
- Pan American Health Organization
- Type
- Procedures, manuals, guidelines
- Edition
- 1st edition, 2024
- Status
- Current
- Published
- 2024-01-01
- Languages
- English, Spanish (original)
- Scope
- Eight major obstetric emergencies: hypertensive disorders, pulmonary thromboembolism, amniotic fluid embolism, COVID-19, influenza, maternal sepsis, cardiopulmonary resuscitation, and postpartum hemorrhage; includes early warning systems and rapid response teams
- Audience
- Obstetricians, midwives, anesthesiologists, intensivists, emergency physicians, and public health professionals managing obstetric emergencies in hospitals and referral centers across the Americas
- Pages
- 164
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- 978-92-75-12851-0 (PDF)
- Evidence
- GRADE-rated recommendations for new chapters (pulmonary thromboembolism, amniotic fluid embolism, COVID-19, influenza, maternal sepsis); updated chapters based on 2019-2022 international guidelines from ACOG, ISSHP, FIGO, WHO, NICE, SOGC, ESC, AHA, ERC with consensus expert adaptation to resource-variable settings
- Record history
- Created 17 Oct 2026 · updated 17 Oct 2026 · next check Apr 2027
Pan American Health Organization. Recommendations for the management of major obstetric emergencies. Washington, D.C.: PAHO; 2024. 164 p. Available from: https://doi.org/10.37774/9789275128510GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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