What are the guidelines for managing postpartum hemorrhage (PPH) due to delivery bleeding?

From the Guidelines

Postpartum hemorrhage management should prioritize the administration of intravenous tranexamic acid within 3 hours of birth, as it has been shown to reduce maternal death due to bleeding in women with clinically diagnosed post-partum haemorrhage 1. The management of postpartum hemorrhage (PPH) requires a stepwise approach to control bleeding, with the primary goal of reducing maternal morbidity and mortality.

• Initial management includes uterine massage and administration of uterotonics, with oxytocin as first-line (10-40 units IV infusion or 10 units IM) 1.
• If bleeding persists, additional medications should be given: methylergonovine (0.2 mg IM every 2-4 hours), misoprostol (800-1000 mcg rectally), or carboprost tromethamine (250 mcg IM every 15-90 minutes, maximum 8 doses).
• Fluid resuscitation with crystalloids and blood products is essential for hemodynamic stability, aiming to maintain hemoglobin above 8 g/dL.
• If medical management fails, surgical interventions should be considered, including uterine tamponade with balloon devices, compression sutures (B-Lynch), uterine artery embolization, or hysterectomy as a last resort. Key points to consider in PPH management include:
• Prompt recognition of excessive bleeding (>500 mL for vaginal delivery or >1000 mL for cesarean) and systematic management are crucial for reducing maternal morbidity and mortality.
• Active management of the third stage of labor can prevent PPH by administering prophylactic oxytocin (10 units IM) after delivery of the anterior shoulder or immediately after birth 1.
• The primary mechanism of PPH is uterine atony, where the uterus fails to contract effectively after delivery, allowing continued bleeding from the placental site. The most recent and highest quality study recommends the use of intravenous tranexamic acid within 3 hours of birth, as it has been shown to reduce maternal death due to bleeding in women with clinically diagnosed post-partum haemorrhage 1.

From the FDA Drug Label

Carboprost tromethamine injection is indicated for the treatment of postpartum hemorrhage due to uterine atony which has not responded to conventional methods of management. Prior treatment should include the use of intravenously administered oxytocin, manipulative techniques such as uterine massage and, unless contraindicated, intramuscular ergot preparations 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 Following delivery of the placenta, for routine management of uterine atony, hemorrhage and subinvolution of the uterus. For control of uterine hemorrhage in the second stage of labor following delivery of the anterior shoulder.

The guidelines for managing postpartum hemorrhage (PPH) due to delivery bleeding include:

• The use of oxytocin (IV) to control postpartum bleeding, with a dose of 10 to 40 units added to 1,000 mL of a nonhydrating diluent and run at a rate necessary to control uterine atony 2
• The use of carboprost tromethamine (IM) for the treatment of postpartum hemorrhage due to uterine atony which has not responded to conventional methods of management, including prior treatment with oxytocin, uterine massage, and ergot preparations 3
• The use of methylergonovine (IM) for routine management of uterine atony, hemorrhage, and subinvolution of the uterus following delivery of the placenta 4 Key steps in managing PPH due to delivery bleeding include:
• Initial treatment with oxytocin
• Use of manipulative techniques such as uterine massage
• Administration of ergot preparations, such as methylergonovine, unless contraindicated
• Consideration of carboprost tromethamine if conventional methods are unsuccessful

From the Research

Guidelines for Managing Postpartum Hemorrhage (PPH) due to Delivery Bleeding

• The primary cause of PPH is uterine atony, accounting for 70% to 80% of cases 5.
• Pharmacotherapy is the first-line preventative therapy for PPH, with oxytocin being the most commonly used uterotonic agent 5, 6.
• Combined therapy, rather than oxytocin alone, is recommended for preventing PPH, as it has an additive or synergistic effect and a greater risk reduction for PPH prevention 5.
• Second-line uterotonics, such as methylergonovine, carboprost, and misoprostol, can be used in combination with oxytocin to prevent PPH 5, 6, 7.
• Tranexamic acid has been found to be effective and safe for decreasing maternal mortality in women with PPH, and prophylactic use may decrease the need for packed red blood cell transfusions and/or uterotonics 5.

Uterotonic Medications

• Oxytocin is the first-line agent for preventing and treating uterine atony 6, 8.
• Methylergonovine and carboprost are highly effective second-line agents, but have severe potential side effects 6, 7.
• Misoprostol is a useful therapeutic in resource-limited practice environments, but its effectiveness as an adjunct to other uterotonic agents has been questioned 6.

Prevention and Management of Uterine Atony

• Active management of the third stage of labor, including the use of uterotonic agents, can help prevent uterine atony 8.
• Risk-factor recognition and identification of patients at high risk for obstetric hemorrhage are critical for timely intervention 9.
• Obstetric-specific hemorrhage protocols, facilitating the integration and timely escalation of pharmacologic, radiological, surgical, and transfusion interventions, are essential for the successful management of peripartum bleeding 9.