What is the standard of care for managing postpartum hemorrhage?

Standard of Care for Postpartum Hemorrhage Management

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, 2

Definition and Diagnosis

• Postpartum hemorrhage (PPH) is defined as blood loss >500 mL after vaginal delivery or >1000 mL after cesarean section 2
• Primary PPH occurs within 24 hours of delivery; secondary PPH occurs between 24 hours and 6 weeks postpartum 2
• Clinical assessment should include continuous monitoring of vital signs and blood loss estimation

First-Line Management

1. Uterine massage - immediate intervention for suspected uterine atony 2
2. Oxytocin administration - 5-10 IU slow IV or IM injection, followed by maintenance infusion (not exceeding cumulative dose of 40 IU) 2, 3
   • For postpartum bleeding control, 10-40 units may be added to 1000 mL of non-hydrating solution and infused at a rate necessary to control uterine atony 3
   • Alternatively, 10 units can be administered IM after placental delivery 3
3. Tranexamic acid - 1g IV administered within 3 hours of bleeding onset 1, 2
   • A second dose of 1g IV may be given if bleeding continues after 30 minutes or restarts within 24 hours 1, 2
   • Efficacy decreases by 10% for every 15-minute delay, emphasizing the importance of early administration 2

Second-Line Management (if first-line fails)

1. Additional uterotonics:

   • Methylergonovine (Methergine) - for uterine atony, hemorrhage, and subinvolution 4
   • Carboprost tromethamine (Hemabate) - for treatment of PPH due to uterine atony that has not responded to conventional management 5

2. Intrauterine balloon tamponade - can be performed if pharmacological management fails and before recourse to surgery or interventional radiology 6

3. Fluid resuscitation and blood product administration:

   • Target hemoglobin levels >8 g/dL 2
   • Maintain fibrinogen levels ≥2 g/L 2, 6
   • Fresh frozen plasma should be considered after 4 units of packed red blood cells 2
   • Point-of-care testing is preferred for monitoring coagulation status 2

Third-Line Management

1. Interventional radiology - arterial embolization if available and patient is hemodynamically stable 2, 6

2. Surgical interventions - if pharmacological and less invasive measures fail:

   • Uterine compression sutures
   • Uterine or internal iliac artery ligation
   • Hysterectomy as last resort 2, 6

Etiology-Based Approach (Four T's)

1. Tone (70-80% of cases): Uterine atony

   • Management: Uterine massage, oxytocin, additional uterotonics

2. Trauma: Lacerations, hematomas, uterine inversion or rupture

   • Management: Surgical repair of lacerations, drainage of hematomas, uterine replacement

3. Tissue: Retained placental tissue, placenta accreta spectrum

   • Management: Manual removal, curettage (with caution), surgical management for accreta

4. Thrombin: Coagulopathies

   • Management: Blood product replacement, correction of specific deficiencies

Special Considerations

• Hospital-to-hospital transfer for embolization is possible once hemoperitoneum is ruled out and if the patient's hemodynamic condition allows 6
• Oxygen administration is recommended in women with severe PPH 6
• Prevent and treat hypothermia by warming infusion solutions and blood products 6

Prevention Strategies

• Active management of the third stage of labor with prophylactic oxytocin (5-10 IU slow IV or IM) is recommended after delivery to reduce PPH incidence 2, 6
• Avoid routine episiotomy to decrease blood loss 7

The management of PPH requires prompt diagnosis, rapid team-based care, and a systematic approach to minimize morbidity and mortality, regardless of cause 7.