What are the best management options for postpartum hemorrhage (PPH) in a patient more than 12 hours postpartum?

From the Guidelines

For postpartum hemorrhage (PPH) occurring more than 12 hours after delivery, the best options include uterotonic medications, surgical interventions, and supportive care, with a focus on identifying and treating the underlying cause, such as retained placental fragments, endometritis, or subinvolution of the placental site, as recommended by the most recent guidelines 1. The management of PPH at this stage should prioritize the patient's hemodynamic stability and morbidity, mortality, and quality of life outcomes.

• First-line treatment is oxytocin (10-40 units in 1L IV fluid at 125-200 mL/hour), which promotes uterine contractions, as supported by the American College of Radiology 1.
• If bleeding persists, methylergonovine (0.2 mg IM every 2-4 hours) or carboprost tromethamine (250 mcg IM every 15-90 minutes, maximum 8 doses) can be added, as suggested by the guidelines 1.
• Tranexamic acid (1g IV over 10 minutes, repeat after 30 minutes if needed) helps stabilize blood clots and should be given within 3 hours of bleeding onset, as recommended by the World Health Organization 1.
• For severe cases unresponsive to medications, surgical options include uterine tamponade with balloon devices, uterine artery embolization, compression sutures, or hysterectomy as a last resort, as indicated by the guidelines 1.
• Concurrent management should include fluid resuscitation, blood product replacement, close monitoring of vital signs, and correction of any coagulopathy, as emphasized by the guidelines 1. The most recent and highest quality study 1 prioritizes the management of PPH in a multidisciplinary maternity referral centre with all necessary specialties for severe or worsening PPH, including anaesthesia and intensive care.

From the FDA Drug Label

To control postpartum bleeding, 10 to 40 units of oxytocin may be added to 1,000 mL of a nonhydrating diluent and run at a rate necessary to control uterine atony Carboprost tromethamine injection is indicated for the treatment of postpartum hemorrhage due to uterine atony which has not responded to conventional methods of management. Following delivery of the placenta, for routine management of uterine atony, hemorrhage and subinvolution of the uterus.

The best options for Postpartum Hemorrhage (PPH) for a patient over 12 hours postpartum are:

• Oxytocin (IV): as a first-line treatment to control uterine atony 2
• Carboprost tromethamine (IM): for the treatment of postpartum hemorrhage due to uterine atony which has not responded to conventional methods of management, including oxytocin 3
• Methylergonovine (IM): for routine management of uterine atony, hemorrhage and subinvolution of the uterus 4 Key considerations:
• Oxytocin should be used as a first-line treatment
• Carboprost tromethamine and methylergonovine can be used if oxytocin is not effective
• The choice of treatment should be based on the individual patient's needs and medical history.

From the Research

Options for PPH Prevention

For a patient over 12 hours postpartum, the following options can be considered for preventing postpartum hemorrhage (PPH):

• Combined therapy rather than oxytocin alone, as it has been found to have a greater risk reduction for PPH prevention 5
• The use of second-line uterotonics such as methylergonovine, misoprostol, and carboprost in combination with oxytocin, which has an additive or synergistic effect 5
• Methylergonovine and oxytocin infusion in combination during the intra-operative and post-operative periods, which has been found to reduce the level of post-partum haemorrhage considerably 6
• Oxytocin as the first-line agent, with methylergonovine and carboprost as highly effective second-line agents 7

Uterotonic Medications

The following uterotonic medications can be used to restore uterine tone:

• Oxytocin: the first-line agent 7
• Methylergonovine: a highly effective second-line agent with severe potential side effects 7
• Carboprost: a highly effective second-line agent with severe potential side effects 7
• Misoprostol: a useful therapeutic in resource-limited practice environments, but its effectiveness as an adjunct to other uterotonic agents has been called into question 7

Prevention of PPH

The prevention of PPH can be achieved through the administration of uterotonic agents, such as:

• Oxytocin: which has been found to be associated with a significant reduction in postpartum blood loss and in frequency of blood loss >500 ml 8
• Methylergometrine: which can be used as an alternative to oxytocin, but has been found to be less effective in preventing PPH 8