Management of Postpartum Hemorrhage
Early administration of tranexamic acid (within 3 hours of birth) at a dose of 1g IV over 10 minutes, alongside oxytocin administration, is strongly recommended as first-line treatment for postpartum hemorrhage to reduce maternal morbidity and mortality. 1, 2, 3
Definition and Diagnosis
- Postpartum hemorrhage (PPH) is defined as blood loss >500 mL after vaginal birth or >1000 mL after cesarean 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
Systematic Management Approach
First-Line Interventions
- Administer oxytocin 5-10 IU slow IV or IM immediately postpartum as the first-line uterotonic 3, 4
- Administer tranexamic acid (TXA) 1g IV over 10 minutes within 3 hours of birth (earlier administration is better, as efficacy decreases by 10% for every 15-minute delay) 1, 2, 3
- Implement non-pharmacological interventions including uterine massage and bimanual compression 3
- Initiate fluid resuscitation with physiologic electrolyte solutions 1, 3
- Obtain baseline laboratory tests (CBC, coagulation profile, crossmatch) 3
- Maintain patient warmth, as clotting factors function poorly at lower temperatures 3
Second-Line Interventions (if bleeding persists)
- Administer a second dose of TXA 1g IV if bleeding continues after 30 minutes or restarts within 24 hours 1, 2
- Switch to second-line uterotonics if oxytocin fails to control bleeding within 30 minutes:
- Consider intrauterine balloon tamponade if pharmacological management fails 3
Third-Line Interventions
- Implement massive transfusion protocol if blood loss exceeds 1500 mL 3
- Consider interventional radiology for arterial embolization, particularly when no single source of bleeding can be identified 3
- Consider surgical interventions if bleeding continues despite medical management:
Management Based on Etiology (Four T's)
Tone (Uterine Atony - 70-80% of cases)
- Administer oxytocin 5-10 IU IV/IM followed by infusion (not to exceed cumulative dose of 40 IU) 3, 4, 7
- Perform uterine massage and bimanual compression 3
- Use second-line uterotonics if oxytocin fails 5, 6
Trauma (20% of cases)
- Examine for lacerations, hematomas, uterine rupture or inversion 3
- Repair lacerations and evacuate hematomas 3
- Address uterine rupture or inversion surgically 3
Tissue (10% of cases)
- Perform manual removal of retained placenta or surgical evacuation of retained products of conception 3
- Use ultrasound to diagnose retained products of conception 3
Thrombin (Coagulopathy - 1% of cases)
- Maintain fibrinogen level ≥2g/L 8
- Administer blood products (RBCs, fibrinogen, fresh frozen plasma) without awaiting laboratory results if necessary 3, 8
Monitoring and Post-Acute Management
- Monitor vital signs continuously during active bleeding 1
- Continue hemodynamic monitoring for at least 24 hours after delivery 1, 3
- Monitor for complications including renal failure, liver failure, infection, and Sheehan syndrome 3
- Re-dose prophylactic antibiotics if blood loss exceeds 1500 mL 3
Common Pitfalls to Avoid
- Delaying TXA administration beyond 3 hours after birth significantly reduces its effectiveness 1, 2, 3
- Administering methylergonovine to patients with hypertension (contraindicated due to risk of vasoconstriction) 1, 6
- Delaying treatment for active hemorrhage while waiting for laboratory results 3
- Failing to maintain normothermia and normal pH, which can impair clotting 3
- Underestimating blood loss, particularly with vaginal delivery 3
Special Considerations
- Combined therapy with oxytocin plus other uterotonics may be more effective than oxytocin alone for prevention of PPH 7
- Careful planning of delivery in women with mechanical heart valves on anticoagulation to minimize bleeding risk 1
- Prostaglandin F analogues should be avoided if an increase in pulmonary artery pressure is undesirable 1