What are the management steps for postpartum hemorrhage (PPH) based on the 4 Ts: tone, tissue, trauma, and thrombin?

Management of Postpartum Hemorrhage Using the 4 Ts Framework

Postpartum hemorrhage should be managed systematically using the 4 Ts mnemonic (Tone, Tissue, Trauma, Thrombin), with immediate administration of tranexamic acid 1 g IV over 10 minutes as the critical first-line intervention alongside uterotonic therapy, as effectiveness declines by 10% for every 15 minutes of delay. 1

Initial Resuscitation and Immediate Interventions

• Administer tranexamic acid (TXA) 1 g IV over 10 minutes immediately upon recognition of PPH, as it reduces bleeding-related mortality when given within 3 hours of delivery and decreases the need for laparotomy 1
• Begin uterine massage to stimulate contractions while simultaneously assessing the cause 2
• Establish IV access and initiate crystalloid resuscitation to maintain hemodynamic stability 3
• Monitor vital signs continuously, including heart rate, blood pressure, and oxygen saturation 3
• Administer supplemental oxygen in cases of severe PPH 4

The 4 Ts: Systematic Cause Identification and Treatment

1. TONE (Uterine Atony) - Most Common Cause (>75% of cases)

Clinical diagnosis: Soft, boggy uterus on palpation 3, 2

Management sequence:

• Bimanual uterine massage as first mechanical intervention 2
• Oxytocin 10 IU IM or slow IV push (over 1-2 minutes), followed by continuous infusion of 20-40 IU in 1000 mL at 150 mL/hour, not exceeding 40 IU cumulative dose 5, 4
• If oxytocin fails within 30 minutes, administer sulprostone as second-line agent 4
• Carboprost tromethamine 250 mcg IM can be used for refractory atony after oxytocin failure 6
• Methylergonovine 0.2 mg IM is an alternative but is absolutely contraindicated in hypertensive patients due to severe vasoconstriction risk 2, 7
• Intrauterine balloon tamponade should be attempted if pharmacologic measures fail before proceeding to surgery or interventional radiology 4

Surgical options for refractory atony:

• Bilateral uterine artery ligation 2
• B-Lynch compression sutures 2
• Hysterectomy as last resort 2

2. TISSUE (Retained Placental Tissue)

Clinical diagnosis: Incomplete placental delivery or retained fragments 8

Management:

• Manual uterine examination with antibiotic prophylaxis to identify and remove retained tissue 4
• Ultrasound can assist in identifying retained products of conception, though this is more common in delayed PPH 3
• Consider intraumbilical injection of oxytocin (10-30 IU) or misoprostol (800 mcg) before manual removal if placenta is adherent 9

3. TRAUMA (Lacerations, Hematomas, Uterine Rupture)

Clinical diagnosis: Continued bleeding despite firm, contracted uterus 8

Management:

• Thorough visual inspection of the cervix, vagina, and perineum to identify lacerations 2
• Immediate surgical repair of identified lacerations with appropriate suturing 8
• CT with IV contrast in hemodynamically stable patients to localize bleeding source and identify hematomas or uterine rupture 3
• Pelvic packing can be highly effective for stabilization in cases of severe intractable pelvic hemorrhage, left in place for 24 hours with open abdomen and ventilatory support 3

4. THROMBIN (Coagulopathy)

Clinical diagnosis: Diffuse oozing from multiple sites, failure to form clots 8

Laboratory assessment:

• Obtain baseline platelet count, PT, PTT, and fibrinogen levels immediately 3
• Fibrinogen <2 g/L occurs in 17% of cases with blood loss >2000 mL and is an early predictor of severe PPH 1
• Point-of-care testing with thromboelastography/thromboelastometry provides rapid results (FIBTEM values decline faster than standard fibrinogen levels) 3, 10

Management:

• Do not wait for laboratory results before transfusing in active hemorrhage 3, 4
• Maintain fibrinogen ≥2 g/L with cryoprecipitate or fibrinogen concentrate 1, 4
• Transfuse packed RBCs, fresh frozen plasma, and platelets in 1:1:1 ratio during massive hemorrhage 2, 11
• Target hemoglobin >8 g/dL 4
• Platelet transfusion is rarely needed unless blood loss exceeds 5000 mL or platelet count <75 × 10⁹/L 1

Critical Supportive Measures

• Prevent hypothermia by warming all infusion solutions and blood products and using active skin warming, as clotting factors function poorly below 36°C 3, 4
• Avoid and correct acidosis, which impairs coagulation 3
• Maintain lateral decubitus positioning to optimize hemodynamics 3
• Re-dose prophylactic antibiotics if blood loss exceeds 1500 mL 3

Advanced Interventions for Refractory Hemorrhage

Interventional radiology:

• Uterine artery embolization should be considered in hemodynamically stable patients who have failed medical management and non-surgical interventions 3, 1
• Transfer for embolization is possible only after ruling out hemoperitoneum and confirming hemodynamic stability 4

Surgical interventions:

• Hypogastric artery ligation may be attempted by experienced surgeons, though efficacy is limited by collateral circulation 3
• Damage control surgery principles apply in cases of deep hemorrhagic shock with ongoing bleeding and coagulopathy 3

Common Pitfalls to Avoid

• Never use methylergonovine in hypertensive patients - risk of severe hypertension and stroke 2, 7
• Avoid hypotonic solutions like Ringer's lactate in patients requiring massive resuscitation 3
• Do not delay TXA administration - effectiveness decreases 10% every 15 minutes 1
• Do not perform rapid IV bolus of oxytocin >10 IU - risk of hypotension and cardiovascular collapse 5
• Do not rely on visual estimation of blood loss - use clinical markers (vital signs, symptoms) and collection bags for accurate assessment 4, 9
• Recognize that prostaglandin F analogues should be avoided when increased pulmonary artery pressure is undesirable 3