What is the management of postpartum vaginal bleeding?

Management of Postpartum Vaginal Bleeding

The management of postpartum hemorrhage (PPH) requires immediate intervention with uterine massage, oxytocin administration (10-40 units in 1000mL IV fluid), and early administration of tranexamic acid (1g IV within 3 hours of bleeding onset) as first-line treatments to reduce maternal morbidity and mortality. 1, 2

Definition and Classification

• PPH is defined as blood loss >500 mL after vaginal delivery or >1000 mL after cesarean section
• Primary PPH: occurs within 24 hours of delivery
• Secondary PPH: occurs between 24 hours and 6 weeks postpartum 1, 2

Initial Assessment and Management

1. Rapid assessment of hemodynamic status

   • Monitor vital signs continuously
   • Estimate blood loss
   • Identify the cause using the "Four T's" mnemonic:
     • Tone (uterine atony, 70-80% of cases)
     • Trauma (lacerations, hematomas)
     • Tissue (retained placental tissue)
     • Thrombin (coagulopathies) 1, 3

2. First-line interventions:

   • Uterine massage - immediate manual compression to stimulate contractions
   • Oxytocin administration:
     • IV infusion: 10-40 units in 1000mL non-hydrating solution at a rate necessary to control uterine atony
     • IM injection: 10 units after placental delivery 4, 1
   • Tranexamic acid: 1g IV within 3 hours of bleeding onset (reduces mortality by 10% for every 15-minute earlier administration) 2, 1

Second-line Interventions

If bleeding continues despite first-line treatments:

1. Additional pharmacological interventions:

   • Second dose of tranexamic acid (1g) if bleeding continues after 30 minutes or restarts within 24 hours 1
   • Carboprost tromethamine (Hemabate): 250 μg IM, may repeat at 15-90 minute intervals as needed (not to exceed 2mg/8 doses) 5

2. Mechanical interventions:

   • Balloon tamponade for uncontrollable bleeding 1
   • Bimanual uterine compression

Advanced Interventions

For refractory bleeding:

1. Interventional radiology:

   • Selective arterial embolization if patient is hemodynamically stable 1, 6

2. Surgical interventions:

   • Uterine compression sutures (B-Lynch, Hayman)
   • Uterine or internal iliac artery ligation 1, 2
   • Hysterectomy as last resort for life-threatening hemorrhage 1

Special Considerations for Secondary PPH

• Ultrasound with Doppler to evaluate for:

  • Retained placental products (RPOC)
  • Vascular uterine abnormalities (VUA)
  • Pseudoaneurysm (showing yin-yang flow pattern) 2

• MRI may be helpful to identify:

  • Endometritis complications (abscess, infected hematoma)
  • Uterine dehiscence
  • Deep-seated pelvic hematomas 2

Blood Product Management

• Target hemoglobin >8 g/dL
• Maintain fibrinogen levels ≥2 g/L
• Use crystalloid fluids for initial volume replacement
• Consider fresh frozen plasma after 4 units of packed red blood cells 1

Recent Evidence for Improved Outcomes

A 2023 randomized trial demonstrated that early detection using calibrated blood-collection drapes combined with bundled treatment (uterine massage, oxytocics, tranexamic acid, IV fluids) reduced the risk of severe PPH, laparotomy for bleeding, or death from bleeding by 60% compared to usual care 7.

Pitfalls to Avoid

• Delayed recognition: Use objective measurements of blood loss rather than visual estimation
• Delayed treatment: Each 15-minute delay in tranexamic acid administration reduces efficacy by 10%
• Inadequate monitoring: Continuous assessment of vital signs and blood loss is essential
• Inappropriate manual removal of placenta: Outside specialized settings, manual removal should only be performed for severe, uncontrollable hemorrhage 2, 1
• Missing rare causes: Consider uncommon etiologies like postpartum acquired hemophilia in cases of persistent bleeding with elevated PTT and normal PT 8

By following this structured approach to management, postpartum hemorrhage can be effectively controlled in most cases, significantly reducing maternal morbidity and mortality.