What is the management of postpartum hemorrhage (PPH)?

Management of Postpartum Hemorrhage (PPH)

The management of postpartum hemorrhage requires early administration of intravenous tranexamic acid (within 3 hours of birth) at a dose of 1g, in addition to standard care including oxytocin administration, for all women with clinically diagnosed PPH following vaginal birth or cesarean section. 1

Definition and Diagnosis

• PPH is defined as blood loss ≥500mL after vaginal delivery or ≥1000mL after cesarean section, or any blood loss sufficient to compromise hemodynamic stability 1, 2
• Severe PPH is defined as blood loss ≥1000mL regardless of delivery route 2
• A collector bag can be used to assess blood loss in cases of overt PPH after vaginal delivery 2

Initial Management Algorithm

First-Line Interventions (Immediate)

1. Uterotonic administration:

   • Oxytocin: 5-10 IU slow IV or IM, followed by maintenance infusion not exceeding 40 IU total 1, 3, 2
   • For control of postpartum bleeding: 10-40 units of oxytocin may be added to 1000mL of non-hydrating solution 3
   • IV route is superior to IM for management of PPH 4

2. Manual examination and physical interventions:

   • Manual uterine examination 2
   • Uterine massage 1, 2
   • Careful visual assessment of the lower genital tract 2
   • Antibiotic prophylaxis 2

3. Fluid resuscitation and supportive care:

   • Initiate fluid resuscitation if bleeding persists after first-line uterotonics 2
   • Administer oxygen in cases of severe PPH 2
   • Prevent and treat hypothermia by warming infusion solutions and blood products 2
   • Monitor vital signs 1

Second-Line Interventions (If Bleeding Continues After 30 Minutes)

1. Additional uterotonics:

   • Sulprostone within 30 minutes of PPH diagnosis if oxytocin fails 2
   • Methylergonovine for routine management of uterine atony and hemorrhage 5
   • Carboprost tromethamine for PPH due to uterine atony that hasn't responded to conventional management 6

2. Tranexamic acid:

   • Administer 1g IV tranexamic acid within 3 hours of birth 1
   • A second dose of 1g IV if bleeding continues after 30 minutes or restarts within 24 hours 1
   • Delay in treatment reduces benefit by 10% for every 15 minutes 1
   • Do not administer beyond 3 hours after birth due to potential harm 1

3. Blood product administration:

   • Maintain hemoglobin concentration >8g/dL 2
   • Maintain fibrinogen level ≥2g/L 2
   • RBC, fibrinogen, and fresh frozen plasma may be administered without awaiting laboratory results in severe cases 2

Third-Line Interventions (If Bleeding Persists)

1. Mechanical interventions:

   • Intrauterine balloon tamponade if pharmacological treatments fail 1, 2
   • Non-pneumatic antishock garment 1
   • External aortic compression 1

2. Invasive procedures:

   • Arterial embolization if available 2
   • Surgical interventions if necessary:
     • Brace sutures 1
     • Arterial ligation 1
     • Hysterectomy as last resort 1

Approach Based on Etiology (Four T's)

1. Tone (Uterine Atony) - most common cause (>75%):

   • Uterotonics as described above
   • Uterine massage
   • Bimanual compression

2. Trauma:

   • Repair of lacerations
   • Management of hematomas
   • Correction of uterine inversion if present
   • CT with IV contrast may help identify surgical causes of PPH 1

3. Tissue:

   • Manual removal of retained placenta only in cases of severe and uncontrollable PPH 1
   • Surgical evacuation if needed

4. Thrombin (Coagulopathy):

   • Blood product replacement
   • Treatment of underlying cause

Important Considerations

• The sequential use of interventions should start with less invasive options, moving toward more invasive interventions as required 1
• Hospital-to-hospital transfer for embolization is possible once hemoperitoneum is ruled out and if the patient's hemodynamic condition allows 2
• Tranexamic acid should be avoided in women with clear contraindications to antifibrinolytic therapy (e.g., known thromboembolic events during pregnancy) 1
• Standardized protocols for oxytocin administration have been associated with decreased PPH treatment rates 7

Prevention of PPH

• Active management of the third stage of labor is recommended 8
• Prophylactic administration of uterotonic agents just after delivery is effective in reducing PPH incidence 2
• Oxytocin is the first-line prophylactic drug, regardless of delivery route 2

By following this systematic approach to PPH management with prompt recognition and escalating interventions as needed, maternal morbidity and mortality can be significantly reduced.