What is the management of uncontrolled postpartum hemorrhage?

From the Guidelines

Management of uncontrolled postpartum hemorrhage requires immediate administration of tranexamic acid 1g IV over 10 minutes, as part of a systematic intervention that includes fluid resuscitation, uterine massage, and uterotonics. The most recent and highest quality study, 1, supports the use of tranexamic acid as a first-line treatment for postpartum hemorrhage, in addition to standard care. This study, published in The Lancet Global Health in 2018, recommends early use of intravenous tranexamic acid within 3 hours of birth, with a fixed dose of 1g intravenously, and a second dose of 1g intravenously if bleeding continues after 30 minutes, or if bleeding restarts within 24 hours of completing the first dose.

Key steps in the management of uncontrolled postpartum hemorrhage include:

• Calling for help and establishing large-bore IV access for fluid resuscitation with crystalloids or blood products
• Performing bimanual uterine massage
• Administering first-line uterotonics: oxytocin 10-40 units IV infusion, methylergonovine 0.2mg IM (contraindicated in hypertension), or misoprostol 800-1000mcg rectally
• Moving to second-line treatments, including tranexamic acid and intrauterine balloon tamponade, if bleeding continues
• Considering surgical interventions, including uterine artery embolization, B-Lynch compression sutures, or hysterectomy, if medical management fails

It is essential to monitor vital signs closely, maintain normothermia, correct coagulopathy with appropriate blood products, and address the specific cause of hemorrhage (uterine atony, retained placenta, lacerations, or coagulopathy) throughout management, as supported by 1 and 1. Prompt recognition and aggressive management are critical to prevent hypovolemic shock and end-organ damage, as postpartum hemorrhage causes 25% of maternal deaths worldwide, with uterine atony being the most common cause, as noted in 1 and 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 In a high proportion of cases, carboprost tromethamine injection used in this manner has resulted in the cessation of life threatening bleeding and the avoidance of emergency surgical intervention.

The management of uncontrolled postpartum hemorrhage includes the use of carboprost tromethamine (IM) 2 after failed conventional methods such as:

• Intravenously administered oxytocin (IV) 3
• Manipulative techniques like utering massage
• Intramuscular ergot preparations like methylergonovine (IM) 4 Key points to consider:
• Carboprost tromethamine is used for uterine atony that has not responded to conventional methods
• Oxytocin (IV) is used to control postpartum uterine bleeding
• Methylergonovine (IM) is used for routine management of uterine atony and hemorrhage

From the Research

Management of Uncontrolled Postpartum Hemorrhage

The management of uncontrolled postpartum hemorrhage involves several key steps and considerations, including:

• Prompt diagnosis and treatment, as emphasized in the study by 5
• Use of the Four T's mnemonic to identify and address the four most common causes of postpartum hemorrhage: uterine atony, trauma, tissue, and thrombin, as noted in 5
• Administration of uterotonic medication, such as oxytocin, to help control bleeding, as discussed in 6 and 7
• Consideration of second-line uterotonics, such as methylergonovine, misoprostol, and carboprost, in combination with oxytocin, as suggested in 7
• Use of tranexamic acid to decrease maternal mortality and reduce the need for packed red blood cell transfusions, as found in 7 and 8

Surgical Management

In cases of severe, uncontrolled postpartum hemorrhage, surgical management may be necessary, including:

• Uterine devascularization, as mentioned in 9
• Uterine tamponade with gauze or specific tubes, as noted in 9
• Selective arterial embolization, as discussed in 9
• Hysterectomy, as a last resort, as mentioned in 8

Multidisciplinary Approach

A standardized, multidisciplinary approach to management is crucial, involving:

• Rapid team-based care to minimize morbidity and mortality, as emphasized in 5
• Early and aggressive resuscitation with large-bore venous accesses, as discussed in 8
• Massive transfusion protocols, with a 4:4:1 RBC:FFP:platelets ratio, as noted in 8
• Use of fibrinogen concentrates and tranexamic acid, as suggested in 8