What are the management options for postpartum hemorrhage (PPH)?

Management of Postpartum Hemorrhage

The first-line treatment for postpartum hemorrhage includes uterotonic medications (primarily oxytocin), with early administration of tranexamic acid within 3 hours of birth, followed by escalating interventions if bleeding persists. 1

Definition and Classification

• Postpartum hemorrhage (PPH) is defined as blood loss >500 mL after vaginal delivery or >1000 mL after cesarean section, or any blood loss sufficient to compromise hemodynamic stability 2, 1
• Primary PPH occurs within 24 hours of delivery; secondary PPH occurs between 24 hours and 6 weeks postpartum 2

Causes of PPH (The Four T's)

1. Tone (70-80% of cases): Uterine atony 1
2. Trauma: Lacerations, hematomas, uterine rupture/dehiscence 2
3. Tissue: Retained placental fragments, placenta accreta spectrum disorders 2
4. Thrombin: Coagulopathies 3

Management Algorithm

Prevention

• Administer prophylactic uterotonics after delivery of the placenta 1, 4
• Oxytocin 5-10 IU slow IV or IM is the first-line prophylactic drug 5, 4

Initial Management (First-Line)

1. Uterotonic medications:

   • Oxytocin: 10-40 units in 1000 mL of non-hydrating solution IV at a rate to control atony 5
   • If IV access unavailable: 10 units IM after placental delivery 5

2. Immediate interventions:

   • Manual uterine examination to assess tone and remove retained tissue 4
   • Uterine massage 2
   • Visual assessment of the lower genital tract for trauma 4
   • Accurate measurement of blood loss (collection bag recommended) 4
   • Fluid resuscitation with crystalloids for persistent bleeding 1, 4

3. Early tranexamic acid administration:

   • 1 g IV (over 10 minutes) within 3 hours of birth 2, 1
   • Second dose of 1 g if bleeding continues after 30 minutes or restarts within 24 hours 1
   • Critical timing: efficacy decreases by 10% for every 15-minute delay 2
   • Contraindicated in women with known thromboembolic events during pregnancy 2

Second-Line Interventions (If Bleeding Persists)

1. Additional uterotonics:

   • Methylergonovine (Methergine): For uterine atony when not contraindicated by hypertension 6
   • Carboprost tromethamine (Hemabate): 250 μg IM for uterine atony unresponsive to oxytocin 7

2. Mechanical interventions:

   • Intrauterine balloon tamponade if pharmacological management fails 1, 4
   • Bimanual compression 1

3. Blood product administration:

   • Target hemoglobin >8 g/dL 1
   • Maintain fibrinogen levels ≥2 g/L 1, 4
   • Consider fresh frozen plasma after 4 units of packed red blood cells 1
   • Implement massive transfusion protocol for blood loss >1500 mL 3

Third-Line Interventions

1. Surgical interventions:

   • Uterine compression sutures (B-Lynch, Hayman) 1
   • Uterine or internal iliac artery ligation 2, 1

2. Interventional radiology:

   • Selective arterial embolization if available and patient is hemodynamically stable 2, 4

3. Definitive management:

   • Hysterectomy as last resort when all other measures fail 1, 8

Critical Considerations

• Prompt recognition and rapid response are essential to minimize morbidity and mortality 8
• Team-based approach with clear communication between obstetrics, anesthesia, and blood bank 3
• Early activation of massive transfusion protocol for severe hemorrhage 3
• Active warming of the patient and infusion solutions to prevent hypothermia 4
• Oxygen administration for women with severe PPH 4
• Point-of-care testing for coagulation status when available 1

Monitoring During Management

• Continuous assessment of vital signs and blood loss 1
• Serial hemoglobin and coagulation studies 4
• Urine output monitoring 8
• Early identification of signs of shock or organ dysfunction 8

Common Pitfalls to Avoid

• Delaying tranexamic acid administration beyond 3 hours (no benefit and potential harm) 2
• Underestimating blood loss (visual estimation often inaccurate) 4
• Focusing solely on uterine atony while missing other causes of bleeding 3
• Delaying escalation to surgical interventions when medical management fails 8
• Inadequate fluid resuscitation and blood product replacement 1, 4

By following this systematic approach to PPH management, clinicians can effectively reduce maternal morbidity and mortality associated with this common but potentially life-threatening obstetric emergency.