What is the treatment for postpartum hemorrhage (PPH)?

Treatment of Postpartum Hemorrhage (PPH)

Early administration of intravenous tranexamic acid (within 3 hours of birth) at a fixed dose of 1g over 10 minutes, with a second dose if bleeding continues after 30 minutes, is strongly recommended for all cases of PPH regardless of cause, in addition to standard care including oxytocin. 1, 2

First-Line Management

1. Immediate assessment and diagnosis

   • PPH is defined as blood loss >500 mL after vaginal delivery or >1000 mL after cesarean section 2
   • Use the "Four T's" approach to identify the cause:
     • Tone (uterine atony, 70-80% of cases)
     • Trauma (genital tract trauma)
     • Tissue (retained placental tissue)
     • Thrombin (coagulopathies) 2, 3

2. Initial pharmacological management

   • Oxytocin: First-line uterotonic
     • 5-10 IU slow IV/IM injection followed by maintenance infusion
     • Total cumulative dose should not exceed 40 IU 2, 4, 5
   • Manual uterine massage and bimanual compression 5, 3
   • Tranexamic acid (TXA): 1g IV over 10 minutes within 3 hours of birth
     • Second dose of 1g if bleeding continues after 30 minutes or restarts within 24 hours
     • Efficacy decreases by 10% for every 15-minute delay 1, 2

Second-Line Management

If bleeding persists after oxytocin and TXA:

1. Second-line uterotonics

   • Sulprostone (prostaglandin E2 analog): Should be administered within 30 minutes of PPH diagnosis if oxytocin fails 5
   • Carboprost tromethamine (prostaglandin F2α analog):
     • 250 μg IM, may repeat at 15-90 minute intervals
     • Maximum total dose: 2 mg (8 doses) 6

2. Mechanical interventions

   • Intrauterine balloon tamponade if pharmacological management fails and before surgical interventions 2, 5

Advanced Interventions

If bleeding continues despite above measures:

1. Fluid resuscitation and blood product management

   • Maintain hemoglobin >8 g/dL 2, 5
   • Maintain fibrinogen levels ≥2 g/L 5
   • Administer crystalloids for initial volume replacement 2
   • Consider fresh frozen plasma after 4 units of packed red blood cells 2
   • Prevent and treat hypothermia by warming infusion solutions and blood products 2, 5
   • Administer oxygen in cases of severe PPH 2, 5

2. Invasive procedures

   • Arterial embolization if patient is hemodynamically stable and facilities available 2, 5, 7
   • Surgical interventions if other measures fail:
     • Uterine compression sutures
     • Uterine or internal iliac artery ligation
     • Hysterectomy as last resort 2, 3

Important Considerations

1. Timing is critical

   • TXA must be given within 3 hours of birth; after this timeframe, it may be harmful 1, 2
   • If pharmacological treatments fail to control bleeding within 30 minutes, proceed to invasive treatments 5, 7

2. Team-based approach

   • Multidisciplinary team including obstetricians, anesthesiologists, and blood bank personnel 7, 3
   • Clear communication and predefined protocols improve outcomes 3, 8

3. Monitoring

   • Continuous assessment of vital signs and blood loss
   • Point-of-care testing for coagulation status when available 2

4. Prevention

   • Active management of the third stage of labor is recommended for all deliveries
   • Prophylactic oxytocin after delivery of the anterior shoulder 2, 9

Common Pitfalls to Avoid

• Delaying TXA administration beyond 3 hours after birth
• Failing to escalate treatment promptly if first-line measures are ineffective
• Underestimating blood loss (consider using collection bags for accurate measurement)
• Not identifying and addressing the specific cause of PPH while simultaneously treating