What is the management of postpartum hemorrhage (PPH)?

Management of Postpartum Hemorrhage (PPH)

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

Definition and Causes

• 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
• Primary PPH occurs within 24 hours of delivery, while secondary PPH occurs between 24 hours and 6 weeks postpartum 2
• Main causes include:
  • Uterine atony (70-80% of cases)
  • Retained placental tissue
  • Genital tract trauma
  • Placenta accreta spectrum disorders
  • Coagulopathies
  • Uterine inversion
  • Uterine rupture 2

Immediate Management Algorithm

1. Recognition and Assessment

   • Measure blood loss (collection bag recommended for overt PPH) 3
   • Assess vital signs continuously
   • Perform manual uterine examination 3
   • Visual assessment of the lower genital tract for trauma 2
   • Administer oxygen in cases of severe PPH 3

2. First-Line Treatment

   • Uterine massage 2
   • Oxytocin 5-10 IU slow IV or IM, followed by maintenance infusion (not exceeding cumulative dose of 40 IU) 3, 4
   • Antibiotic prophylaxis with manual uterine examination 3
   • Fluid resuscitation if persistent bleeding or clinical signs of severity 3

3. Second-Line Treatment (if bleeding persists after 30 minutes)

   • Tranexamic acid 1g IV (within 3 hours of birth) 1, 2
   • Second dose of tranexamic acid 1g if bleeding continues after 30 minutes or restarts within 24 hours 2
   • Sulprostone (prostaglandin E2 analog) within 30 minutes of PPH diagnosis if oxytocin fails 3
   • Carboprost tromethamine (15-methyl prostaglandin F2α) IM for uterine atony unresponsive to conventional management 5
   • Methylergonovine IM for uterine atony (contraindicated in hypertensive patients) 6

4. Third-Line Treatment

   • Intrauterine balloon tamponade if pharmacological treatments fail 3, 2
   • Blood product administration:
     • Target hemoglobin >8 g/dL 2
     • Maintain fibrinogen levels ≥2 g/L 3, 2
     • Consider RBC, fibrinogen, and fresh frozen plasma without awaiting laboratory results in severe cases 3

5. Surgical Interventions (if bleeding persists)

   • Arterial embolization (if patient is hemodynamically stable) 2, 3
   • Conservative surgical techniques (no specific technique favored):
     • Uterine compression sutures (B-Lynch, Hayman)
     • Uterine or internal iliac artery ligation 2, 3
   • Hysterectomy as last resort 2, 7

Key Points for Optimal Management

• Timing is critical: Early intervention with tranexamic acid (within 3 hours) is crucial, with efficacy decreasing by 10% for every 15-minute delay 2
• Team-based approach: Rapid, coordinated response is essential to minimize morbidity and mortality 8
• Prevention: Active management of the third stage of labor with prophylactic oxytocin administration is recommended for all deliveries 3, 8
• Route of oxytocin: IV oxytocin may be superior to IM for PPH management 9
• Standardized protocols: Implementation of standardized oxytocin protocols may reduce PPH treatment rates 10
• Temperature management: Prevent and treat hypothermia by warming infusion solutions, blood products, and active skin warming 3
• Laboratory monitoring: Coagulation screens should be performed as soon as persistent PPH is diagnosed 7

Common Pitfalls and Caveats

• Delayed recognition: Failure to promptly recognize and respond to PPH increases morbidity and mortality
• Underestimation of blood loss: Visual estimation often underestimates actual blood loss; quantitative methods are preferred
• Focusing only on uterine atony: Remember to consider all potential causes (4 T's: Tone, Trauma, Tissue, Thrombin) 8
• Delayed escalation: Failure to escalate treatment in a timely manner if first-line measures are ineffective
• Tranexamic acid timing: Efficacy decreases significantly if administered more than 3 hours after birth 1, 2
• Inappropriate transfer: Hospital-to-hospital transfer for embolization should only be considered after ruling out hemoperitoneum and ensuring hemodynamic stability 3