What is the management of postpartum hemorrhage (PPH)?

Management of Postpartum Hemorrhage (PPH)

The management of postpartum hemorrhage requires immediate administration of oxytocin as first-line treatment, followed by tranexamic acid within 3 hours of bleeding onset, and escalation to additional uterotonics and surgical interventions as needed based on response. 1

Definition and Diagnosis

• Postpartum hemorrhage (PPH) is defined as blood loss >500 mL after vaginal delivery or >1000 mL after cesarean section, or any blood loss sufficient to compromise hemodynamic stability 1, 2
• PPH is a major contributor to maternal mortality worldwide, with a person dying approximately every 5 minutes due to this condition 2

First-Line Management

• Administer oxytocin immediately upon recognition of PPH 1:
  • IV route: 10-40 units in 1000 mL of non-hydrating solution at a rate necessary to control uterine atony 3
  • IM route: 10 units after delivery of the placenta 3
  • IV route is more effective than IM for PPH prevention (11.1% less blood loss with IV bolus compared to IM) 4, 5
• Implement early administration of tranexamic acid (TXA) within 3 hours of birth 1:
  • Fixed dose of 1 g IV given over 10 minutes (1 mL/min) 1
  • Second dose of 1 g IV if bleeding continues after 30 minutes or restarts within 24 hours 1
  • Do not administer TXA beyond 3 hours after birth as it may be potentially harmful 1, 6

Non-Pharmacological Interventions

• Perform uterine massage to stimulate contractions 1, 2
• Implement bimanual compression for continued bleeding 1
• Apply intrauterine balloon tamponade if bleeding persists 1
• Consider non-pneumatic antishock garment for temporary stabilization 1
• Apply external aortic compression in severe cases 1

Second-Line Pharmacological Interventions

• If oxytocin fails to control bleeding, consider additional uterotonics 1, 7:
  • Carboprost tromethamine (15-methyl PGF2α): indicated for PPH due to uterine atony unresponsive to conventional management including oxytocin 7
  • Methylergonovine: for control of uterine hemorrhage, but contraindicated in hypertensive patients 8
  • Note: Prostaglandin F analogues should be used with caution if increased pulmonary artery pressure is a concern 1

Surgical Interventions (if medical management fails)

• Progress from less to more invasive interventions as required 1:
  • Brace sutures (B-Lynch or similar) 1
  • Arterial ligation 1
  • Hysterectomy as last resort for life-threatening hemorrhage 1

Blood Product Administration

• Implement massive transfusion protocol if significant ongoing hemorrhage 9
• Transfuse packed red blood cells, fresh frozen plasma, and platelets in a fixed ratio 9
• Monitor laboratory parameters (platelet count, prothrombin time, partial thromboplastin time, and fibrinogen levels) 9

Monitoring and Supportive Care

• Continue hemodynamic monitoring for at least 24 hours after delivery 1
• Maintain patient temperature >36°C as clotting factors function poorly at lower temperatures 9
• Avoid acidosis which can impair coagulation 9
• Monitor vital signs and uterine tone continuously 3

Optimizing Oxytocin Administration

• Higher-dose oxytocin regimens (80 IU/500 mL over 1-4 hours) have been associated with lower rates of PPH compared to lower doses (10-30 IU) 10, 11
• Standardized oxytocin protocols (e.g., 60 units over 5.25 hours postdelivery) have been shown to reduce PPH treatment rates 11

Important Caveats and Pitfalls

• Tranexamic acid should be given in all cases of PPH, regardless of whether bleeding is due to genital tract trauma or other reasons 1
• Do not delay treatment waiting for laboratory results; treat based on clinical presentation 9
• Manual removal of the placenta should not be performed routinely to reduce PPH risk, except in cases of severe and uncontrollable hemorrhage 1
• Methylergonovine is contraindicated due to risk (>10%) of vasoconstriction and hypertension 1
• Have a low threshold for reoperation if there is suspected ongoing bleeding after initial management 9