What is the management of postpartum hemorrhage?

Management of Postpartum Hemorrhage

The management of postpartum hemorrhage requires immediate implementation of a structured protocol including uterotonic medications, blood product replacement, and surgical interventions when necessary to reduce maternal morbidity and mortality.

Initial Assessment and Management

Team Approach

• Designate a team leader to coordinate management 1
• Assign a communications lead to interact with laboratories and other departments 1
• Allocate personnel for blood sample transport and securing IV access 1

Immediate Actions

1. Control obvious bleeding points (pressure, tourniquet, hemostatic dressings) 1
2. Administer high FiO2 1
3. Secure large-bore IV access (8-Fr central access ideal in adults) 1
4. Obtain baseline labs: FBC, PT, aPTT, fibrinogen, and cross-match 1
5. Consider near-patient testing (TEG/ROTEM) if available 1
6. Actively warm the patient and all transfused fluids 1

Pharmacological Management

First-Line Treatment

• Administer oxytocin 5-10 IU slow IV or IM at the time of shoulder release or immediately postpartum to prevent postpartum hemorrhage 1
• For treatment of established PPH: IV infusion with 10-40 units of oxytocin in 1,000 mL of non-hydrating diluent at a rate necessary to control uterine atony 2

Second-Line Treatment

• If no response to oxytocin, administer tranexamic acid 1g IV within 1-3 hours of bleeding onset 1
  • May repeat dose after 30 minutes if bleeding persists 3
• Consider methylergonovine IM for management of uterine atony and hemorrhage 4
• For refractory cases, administer carboprost tromethamine IM when PPH has not responded to conventional methods including oxytocin, uterine massage, and ergot preparations 5

Blood Product Replacement

Massive Transfusion Protocol

• Implement massive transfusion protocol with ratio of 1:1:1 to 1:2:4 (packed red cells:fresh frozen plasma:platelets) 3
• Maintain fibrinogen levels >200 mg/dL 1
• Consider cell salvage if available 3

Monitoring During Resuscitation

• Monitor for hypofibrinogenemia, which is the biomarker most predictive of severe PPH 1
• Consider viscoelastic coagulation testing (thromboelastography or rotational thromboelastometry) for rapid assessment 1
• Keep patient warm (>36°C) as many clotting factors function poorly at lower temperatures 1
• Avoid acidosis 1
• Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL 1

Surgical and Interventional Management

For Persistent Bleeding

1. Examine for trauma-related hemorrhage (lacerations, uterine rupture, incision extensions) 1
2. Check for retained placental fragments 1
3. Consider manual removal of placenta only in cases of severe and uncontrollable PPH 1

Advanced Interventions

• Consider pelvic pressure packing for acute uncontrolled hemorrhage 1
• Interventional radiology for embolization of hypogastric arteries when no single source of bleeding can be identified 1
• Consider hypogastric artery ligation, though efficacy is not proven due to collateral circulation 1

Postoperative Care

• Provide intensive hemodynamic monitoring in ICU setting 1
• Maintain vigilance for ongoing bleeding with low threshold for reoperation 1
• Monitor for complications: renal failure, liver failure, infection, unrecognized injuries, pulmonary edema, and DIC 1
• Consider Sheehan syndrome in cases of severe hypoperfusion 1

Common Causes of PPH (Four T's)

1. Tone: Uterine atony (most common cause, >75% of cases) 1
2. Trauma: Lacerations, uterine rupture, incision extensions 1
3. Tissue: Retained placental fragments (second most common cause) 1
4. Thrombin: Coagulopathy (inherited or acute) 1

Special Considerations

• CT with IV contrast may be useful in hemodynamically stable patients when conventional treatment has been unsuccessful, particularly for suspected intra-abdominal hemorrhage 1
• In cases of placenta accreta spectrum, leave placenta in situ and consider cesarean hysterectomy 3
• For patients with placenta accreta spectrum, consider preoperative placement of ureteric stents if bladder involvement is suspected 3

The key to successful management of PPH is rapid recognition, team-based approach, and prompt escalation of interventions when initial measures fail. Early administration of uterotonics and tranexamic acid within the critical time window can significantly reduce maternal mortality from hemorrhage.