What is the management for postpartum hemorrhage (PPH)?

Management of Postpartum Hemorrhage

The management of postpartum hemorrhage (PPH) should include early administration of intravenous tranexamic acid (within 3 hours of birth) at a dose of 1g over 10 minutes, alongside oxytocin administration (5-10 IU IV/IM) and other standard measures to reduce maternal morbidity and mortality. 1, 2

Definition and Diagnosis

• PPH is defined 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 2
• PPH is the leading cause of maternal mortality globally, with most deaths occurring within the first 24 hours after birth 2

First-Line Management

• Oxytocin administration: 5-10 IU slow IV or intramuscular infusion immediately postpartum to reduce PPH incidence 1

  • For IV administration: 10 IU diluted in 1000 mL of non-hydrating solution (creating a 10 mU/mL solution) 3
  • For control of postpartum bleeding: 10-40 units may be added to 1000 mL of non-hydrating diluent and run at a rate necessary to control uterine atony 3
  • IV route is more effective than IM for PPH prevention 4, 5

• Tranexamic acid: Administer 1g IV over 10 minutes (100 mg/mL at 1 mL/min) within 3 hours of birth 1, 2

  • A second dose of 1g should be given if bleeding continues after 30 minutes or restarts within 24 hours 2
  • Must be administered within 3 hours of birth, as delay reduces benefit by approximately 10% for every 15 minutes 2
  • Should not be given beyond 3 hours after birth as it may be potentially harmful 2, 6

Additional Management Measures

• Fluid replacement: Initiate IV fluid resuscitation with physiologic electrolyte solutions 1, 2
• Continuous monitoring: Monitor vital signs, uterine tone, and blood loss 2
• Non-surgical interventions:
  • Bimanual uterine compression 2
  • Intrauterine balloon tamponade 2
  • Non-pneumatic antishock garment 2
  • External aortic compression 2

Second-Line Management

• Additional uterotonics if bleeding persists:

  • Carboprost tromethamine (prostaglandin F2α): Indicated for treatment of PPH due to uterine atony that has not responded to conventional management including oxytocin 7
  • Methylergonovine: Can be used for control of uterine hemorrhage, but is contraindicated in patients with hypertension due to risk of vasoconstriction 1, 8

• Manual removal of placenta: Should not be routinely performed except in cases of severe and uncontrollable PPH 1

Surgical Interventions (When Necessary)

• Implement in a stepwise approach if medical management fails 2:
  • Brace sutures 2
  • Arterial ligation 2
  • Hysterectomy (as last resort) 2

Special Considerations

• Sequential use of interventions should start with less invasive approaches, moving toward more invasive interventions as required 2
• In women with mechanical heart valves on anticoagulation, careful planning of delivery is essential to minimize bleeding risk 1
• Prostaglandin F analogues are useful to treat PPH unless an increase in pulmonary artery pressure is undesirable 1
• Methylergonovine is contraindicated in patients with hypertension due to risk of vasoconstriction and hypertension (>10% risk) 1

Monitoring After Initial Management

• Continue hemodynamic monitoring for at least 24 hours after delivery, as this period has significant hemodynamic changes and fluid shifts that may precipitate heart failure in women with structural heart disease 1
• Monitor for signs of ongoing bleeding and need for additional interventions 2