Management of Postpartum Hemorrhage
The management of postpartum hemorrhage (PPH) requires a systematic approach starting with early administration of intravenous tranexamic acid (within 3 hours of birth) at a dose of 1g over 10 minutes, alongside standard care including uterotonic agents, fluid replacement, and escalating to surgical interventions when necessary. 1
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 1
- PPH is the leading cause of maternal mortality globally, with most deaths occurring within the first 24 hours after birth 2
First-Line Management
- Administer oxytocin 5-10 IU slow IV or intramuscular injection immediately postpartum 3, 1
- For IV infusion, add 10 units of oxytocin to 1,000 mL of physiologic electrolyte solution and run at a rate necessary to control uterine atony 3
- Begin fluid resuscitation with physiologic electrolyte solutions 1, 3
- Implement uterine massage and bimanual compression as immediate non-pharmacological interventions 1
- Monitor vital signs continuously to assess response to treatment 1
Tranexamic Acid Administration
- Administer tranexamic acid (TXA) 1 g (100 mg/mL) intravenously at 1 mL/min (over 10 minutes) 1, 4
- TXA must be given within 3 hours of birth, as delay reduces benefit by approximately 10% for every 15 minutes 4, 1
- A second dose of 1 g should be administered if bleeding continues after 30 minutes or restarts within 24 hours 1
- TXA is contraindicated in women with a known thromboembolic event during pregnancy 4, 5
- Do not administer TXA beyond 3 hours after birth as it may be potentially harmful 4, 1
Second-Line Uterotonics
- If bleeding persists despite oxytocin, administer:
Non-Surgical Interventions
- Implement intrauterine balloon tamponade if pharmacological management fails 1
- Consider non-pneumatic antishock garment for temporary stabilization while arranging definitive care 1
- External aortic compression can be used as a temporizing measure in severe cases 1
Surgical Interventions
- Progress to surgical interventions if bleeding continues despite medical management and non-surgical approaches 1
- Options include:
Blood Product Administration
- Implement massive transfusion protocol for severe hemorrhage exceeding 1,500 mL 8
- Consider early balanced transfusion with appropriate plasma-to-red blood cell ratios 9, 10
- Monitor for and correct coagulopathy, which may develop rapidly in severe PPH 9
Specific Management Based on Etiology (4 T's)
- Tone (Uterine Atony): Primary management with uterotonics and massage 11, 8
- Trauma: Repair lacerations; evacuate hematomas; address uterine rupture or inversion 11, 4
- Tissue: Manual removal of retained placenta or surgical evacuation of retained products of conception 11, 1
- Thrombin (Coagulopathy): Correct with appropriate blood products and monitor coagulation parameters 11, 9
Imaging Considerations
- Ultrasound can help diagnose retained products of conception, showing an echogenic endometrial mass with vascularity 4
- CT with IV contrast can be useful in hemodynamically stable patients to localize bleeding sources, particularly for intra-abdominal hemorrhage 4
- CT can detect vascular complications such as bladder flap hematomas, subfascial hematomas, or perivaginal space hematomas 4
Common Pitfalls and Considerations
- Delay in TXA administration significantly reduces its effectiveness 4, 1
- Small (<4 cm) subfascial and bladder flap hematomas may not be clinically significant 4
- Methylergonovine is contraindicated in patients with hypertension due to risk of vasoconstriction 1, 6
- Continue hemodynamic monitoring for at least 24 hours after delivery, as this period has significant hemodynamic changes 1