What is the management for heavy bleeding postpartum (postpartum hemorrhage)?

Management of Postpartum Hemorrhage

Oxytocin is the first-line pharmacological treatment for postpartum hemorrhage (PPH), followed by tranexamic acid (TXA), which should be administered within 3 hours of birth for all women with clinically diagnosed PPH. 1

Definition and Diagnosis

• PPH is defined as blood loss >500 mL after vaginal delivery or >1000 mL after cesarean section 1
• Primary PPH occurs within 24 hours of delivery; secondary PPH occurs between 24 hours and 6 weeks postpartum 1
• Objective measurement techniques (volumetric and gravimetric) should be used instead of visual estimation, which is notoriously inaccurate 1

Causes of PPH (Four T's)

1. Tone (70-80% of cases): Uterine atony
2. Trauma: Lacerations, hematomas, uterine inversion, uterine rupture
3. Tissue: Retained placental tissue, placenta accreta spectrum disorders
4. Thrombin: Coagulopathies 1, 2

Management Algorithm

First-Line Interventions

1. Uterine massage and bimanual compression

2. Oxytocin: First-line pharmacological treatment 1

   • Initial IV bolus followed by infusion
   • Higher doses (80 IU/500 mL over 1-4 hours) may be more effective than lower doses (10-30 IU) in preventing PPH 3

3. Tranexamic acid (TXA):

   • Administer 1g IV over 10 minutes within 3 hours of birth
   • Give second dose if bleeding continues after 30 minutes 1

Second-Line Interventions (if bleeding persists)

1. Additional uterotonics:

   • Methergine (ergometrine): For routine management after delivery of placenta; postpartum atony and hemorrhage 4
   • Carboprost tromethamine (Hemabate): For treatment of PPH due to uterine atony that hasn't responded to conventional management including IV oxytocin, uterine massage, and ergot preparations 5
   • Misoprostol: Alternative if other uterotonics unavailable 1

2. Intrauterine balloon tamponade if pharmacological management fails 1

Third-Line Interventions

1. Surgical interventions:

   • Uterine compression sutures
   • Uterine or internal iliac artery ligation
   • Hysterectomy (ultimate life-saving procedure) 1, 6

2. Interventional radiology:

   • Arterial embolization if patient is hemodynamically stable and facilities available 1

Blood Product Management

• Target hemoglobin >8 g/dL
• Maintain fibrinogen levels >2 g/L (hypofibrinogenemia is most predictive of severe PPH) 1
• If ongoing bleeding after 4 units of RBC, give 4 units of FFP and maintain 1:1 ratio until coagulation results available 1
• Consider cryoprecipitate or fibrinogen concentrate if fibrinogen <2 g/L 1

Monitoring and Supportive Care

• Continuous assessment of vital signs and blood loss
• Administer oxygen in severe PPH
• Prevent hypothermia (maintain body temperature >36°C) as clotting factors function poorly at lower temperatures 1
• Use crystalloid fluids for initial volume replacement 1

Prevention Strategies

• Active management of the third stage of labor:
  • Oxytocin administration after delivery of anterior shoulder (most important component)
  • Controlled cord traction
  • Uterine massage after placental delivery 2
• Avoid routine episiotomy to decrease blood loss 2
• Identify high-risk patients (previous PPH, advanced maternal age, prolonged labor, pre-eclampsia, obesity, multiple pregnancy, macrosomia) 7

Common Pitfalls and Caveats

1. Delayed recognition: Objective measurement of blood loss is essential as visual estimation often underestimates actual loss
2. Focusing only on uterine atony: Remember to systematically evaluate for all causes (Four T's)
3. Delayed TXA administration: Must be given within 3 hours of birth for maximum benefit
4. Inadequate team response: Rapid team-based care minimizes morbidity and mortality
5. Overlooking coagulopathy: Monitor and correct fibrinogen levels promptly

Early recognition, systematic evaluation of causes, and prompt escalation of interventions following a structured approach are crucial for successful management of PPH and prevention of maternal morbidity and mortality.