What is the recommended treatment for postpartum hemorrhage (PPH)?

Management of Postpartum Hemorrhage (PPH)

The recommended first-line treatment for postpartum hemorrhage is immediate administration of oxytocin 5-10 IU slow IV or intramuscular injection, followed by tranexamic acid 1g IV within 3 hours of bleeding onset if bleeding continues. 1, 2

Initial Assessment and Management

1. Establish IV access immediately to ensure medication administration and fluid resuscitation 1

2. Administer oxytocin as first-line treatment:

   • 5-10 IU slow IV or intramuscular injection 2, 3
   • For ongoing hemorrhage, higher infusion doses (up to 80 IU/500 mL) appear more effective than lower doses 4
   • IV administration is superior to IM for management of PPH 5

3. Identify the cause using the Four T's mnemonic:

   • Tone: Uterine atony (most common cause, >75% of cases) 2
   • Trauma: Lacerations, hematoma, uterine rupture
   • Tissue: Retained placental fragments
   • Thrombin: Coagulopathy

Escalating Treatment Algorithm

For Uterine Atony (First-line interventions)

1. Uterine massage and continued oxytocin 2, 1
2. Tranexamic acid 1g IV within 1-3 hours of bleeding onset 2, 1
   • Reduces maternal mortality when given within this timeframe
   • Should not be delayed while waiting for other interventions

Second-line Interventions

1. Additional uterotonics if bleeding continues:

   • Carboprost tromethamine (15-methyl PGF2α) 250 μg IM, may repeat every 15-90 minutes (maximum 8 doses/2mg) 6
   • Avoid prostaglandin F2α in women with asthma as it may cause bronchoconstriction 2
   • Avoid ergometrine in women with hypertension or asthma 2, 1

2. Blood product administration if significant bleeding continues:

   • If coagulation tests are not known, withhold FFP until four units of RBC have been given 2
   • After four units of RBC, give four units of FFP and maintain 1:1 ratio until coagulation results are available 2
   • Monitor fibrinogen levels - a level <2 g/L with ongoing bleeding requires fibrinogen replacement 2

Third-line Interventions

1. Imaging and interventional procedures:

   • CT with IV contrast or CTA to identify bleeding source if conventional treatment fails 2
   • Consider embolization in hemodynamically stable patients 2

2. Surgical management if bleeding continues despite medical management:

   • Uterine or ovarian artery ligation
   • Uterine compression sutures
   • Hysterectomy as ultimate life-saving procedure 7

Special Considerations

• Point-of-care testing is recommended to guide blood product replacement in ongoing hemorrhage 2
• Manual removal of placenta should not be performed except in cases of severe, uncontrollable hemorrhage 2, 1
• Cell salvage is recommended if abnormal bleeding occurs during cesarean section (use leucocyte filter for autotransfusion) 2
• Cumulative blood loss measurement using volumetric and gravimetric techniques is more accurate than visual estimation 2

Common Pitfalls to Avoid

1. Delayed recognition of PPH - define as blood loss ≥500 mL after vaginal delivery or ≥1000 mL after cesarean delivery
2. Underestimating blood loss - visual estimation is often inaccurate; use quantitative methods 2
3. Delayed administration of tranexamic acid - must be given within 3 hours of bleeding onset 2
4. Inappropriate use of prostaglandins in women with asthma 2
5. Protocol-driven blood product use without laboratory guidance can lead to overtransfusion of FFP 2

Early recognition, prompt intervention with appropriate uterotonic agents, and a systematic approach to escalating care are essential to reduce morbidity and mortality from this potentially life-threatening complication.