What are the latest guidelines for managing postpartum hemorrhage (PPH)?

Latest Guidelines on Management of Postpartum Hemorrhage (PPH)

WHO strongly recommends early use of intravenous tranexamic acid (within 3 hours of birth), in addition to standard care for women with clinically diagnosed postpartum hemorrhage following vaginal birth or caesarean section. 1

Definition and Diagnosis of PPH

• PPH is clinically diagnosed as blood loss of more than 500 mL after vaginal birth or 1000 mL after caesarean section, or any blood loss sufficient to compromise hemodynamic stability 1
• PPH is the leading cause of maternal mortality globally, with most deaths occurring within the first 24 hours after birth 1

First-Line Management of PPH

• Active management of the third stage of labor should be used routinely to prevent PPH 2
• Oxytocin is the first-line uterotonic for both prevention and treatment of PPH 3, 4
  • For treatment of postpartum bleeding: 10-40 units of oxytocin may be added to 1,000 mL of non-hydrating solution and run at a rate necessary to control uterine atony 5
  • Alternatively, 10 units can be given intramuscularly after delivery of the placenta 5

Tranexamic Acid (TXA) Administration

• TXA should be administered at a fixed dose of 1 g (100 mg/mL) intravenously at 1 mL/min (over 10 minutes) 1
• A second dose of 1 g should be given if bleeding continues after 30 minutes or restarts within 24 hours of the first dose 1
• TXA should be given in all cases of PPH, regardless of whether bleeding is due to genital tract trauma or other reasons, including uterine atony 1
• TXA must be administered within 3 hours of birth, as delay reduces benefit by approximately 10% for every 15 minutes 1
• TXA should not be given beyond 3 hours after birth as it may be potentially harmful 1
• TXA is contraindicated in women with a known thromboembolic event during pregnancy 6

Second-Line Management for Uterine Atony

• If oxytocin fails to control hemorrhage, additional uterotonics should be considered 7, 3:
  • Methylergonovine: for routine management of uterine atony and hemorrhage 8
  • Carboprost tromethamine: indicated for PPH due to uterine atony that has not responded to conventional management including oxytocin 7
• When oxytocin does not restore uterine tone, a uterotonic with a different mechanism of action should be chosen early 3
• Carbetocin has been shown to be probably superior to oxytocin in reducing blood loss and the need for additional uterotonics 9

Comprehensive PPH Management

• Standard treatment package for PPH includes 1:
  • Fluid replacement
  • Treatment with uterotonics
  • Monitoring of vital signs
  • Non-surgical interventions (bimanual compression, intrauterine balloon tamponade, non-pneumatic antishock garment, external aortic compression)
  • Surgical interventions (brace sutures, arterial ligation, or hysterectomy) when necessary
• Sequential use of interventions should start with less invasive approaches, moving toward more invasive interventions as required 1
• For massive hemorrhage (>1,500 mL blood loss), massive transfusion protocols should be activated 2, 10
• The "Four T's" mnemonic can help identify the cause of PPH: Tone (uterine atony), Trauma (lacerations, hematoma), Tissue (retained placenta), and Thrombin (coagulopathy) 2

Implementation Considerations

• Health facilities providing emergency obstetric care need appropriate supplies and trained staff to administer TXA safely by intravenous infusion 1
• Rapid team-based care is essential to minimize morbidity and mortality associated with PPH 2
• Slow injection of all uterotonics is strongly recommended to minimize cardiovascular side effects 3