What is the management of postpartum hemorrhage (PPH)?

Management of Postpartum Hemorrhage (PPH)

Early administration of intravenous tranexamic acid (within 3 hours of birth) is strongly recommended in addition to standard care for women with clinically diagnosed postpartum hemorrhage following vaginal birth or cesarean section. 1

Definition and Diagnosis

Postpartum hemorrhage is defined as:

• Blood loss ≥500 mL after delivery (any route)
• Severe PPH: blood loss ≥1000 mL after delivery (any route)
• Or any blood loss sufficient to compromise hemodynamic stability 1, 2

Prevention of PPH

First-line Preventive Measures

• Administer prophylactic uterotonic agents immediately after delivery of the baby 2
• Oxytocin is the first-line prophylactic drug (Grade A) 2:
  • 5-10 IU slow IV or IM at the time of shoulder release or immediately postpartum 1, 3
  • Can be administered either IV or IM (IV route may be more effective) 4

Additional Preventive Measures

• After vaginal delivery:
  • Routine cord drainage, controlled cord traction, uterine massage, and routine bladder voiding are not systematically recommended 2
• After cesarean delivery:
  • Placental delivery by controlled cord traction is recommended 2

Management Algorithm for PPH

1. Immediate Response (First 30 minutes)

• Recognize PPH and call for help
• Assess vital signs and blood loss (consider using a collection bag) 2
• Manual uterine examination with antibiotic prophylaxis 2
• Careful visual assessment of the lower genital tract 2
• Uterine massage 2
• Administer oxytocin 5-10 IU slow IV or IM, followed by maintenance infusion (not exceeding cumulative dose of 40 IU) 2
• Start fluid resuscitation if bleeding persists or signs of clinical severity 2
• Administer oxygen in cases of severe PPH 2

2. If Bleeding Continues (30-60 minutes)

• Administer second-line uterotonics if oxytocin fails to control bleeding within 30 minutes:
  • Sulprostone (prostaglandin E2 analog) 2
  • Carboprost tromethamine (15-methyl prostaglandin F2α) 250 μg IM, may repeat at 15-90 minute intervals (maximum 8 doses) 5
  • Methylergonovine 0.2 mg IM (contraindicated in hypertensive patients) 6
• Tranexamic acid 1 g IV (given over 10 minutes), with a second dose of 1 g IV if bleeding continues after 30 minutes or restarts within 24 hours 1
  • Must be given within 3 hours of birth for effectiveness 1
  • Benefit decreases by 10% for every 15-minute delay 1

3. If Bleeding Still Persists (>60 minutes)

• Intrauterine balloon tamponade if pharmacological measures fail 2
• Blood product administration:
  • Maintain hemoglobin >8 g/dL 2
  • Maintain fibrinogen level ≥2 g/L 2
  • RBC, fibrinogen, and fresh frozen plasma may be administered without awaiting laboratory results in severe cases 2
• Prevent and treat hypothermia by warming infusion solutions and blood products 2

4. Invasive Interventions (if medical management fails)

• Arterial embolization or surgical intervention 2
• No specific conservative surgical technique is favored over others 2
• Hospital-to-hospital transfer for embolization is possible if hemoperitoneum is ruled out and patient is hemodynamically stable 2

Approach Based on Cause of PPH (Four T's)

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

   • Uterine massage
   • Uterotonics (oxytocin, prostaglandins, ergot alkaloids)
   • Intrauterine balloon tamponade

2. Trauma

   • Repair of lacerations
   • Drainage of hematomas
   • Correction of uterine inversion
   • Repair of uterine rupture

3. Tissue

   • Manual removal of retained placenta or placental fragments
   • Surgical evacuation if necessary

4. Thrombin (Coagulopathy)

   • Blood product replacement
   • Treatment of underlying cause (amniotic fluid embolism, placental abruption, HELLP syndrome)

Important Considerations

• Tranexamic acid is most effective when given early (within 3 hours of birth) and should not be given after this time frame 1
• Massive transfusion protocols should be activated for blood loss exceeding 1,500 mL 7
• Rapid team-based care is essential to minimize morbidity and mortality 7
• CT imaging may be considered in hemodynamically stable patients when conventional medical treatment has been unsuccessful, particularly for suspected intra-abdominal hemorrhage or postsurgical complications 1

Pitfalls to Avoid

• Delaying tranexamic acid administration beyond 3 hours after birth (may be potentially harmful) 1
• Failing to recognize and treat PPH promptly
• Not escalating to second-line treatments within 30 minutes if first-line treatment fails
• Overlooking non-atonic causes of PPH (trauma, retained tissue, coagulopathy)
• Inadequate fluid resuscitation and blood product replacement