What is the management of Postpartum Hemorrhage (PPH)?

Management of Postpartum Hemorrhage

Immediately administer tranexamic acid 1 g IV over 10 minutes alongside oxytocin 5-10 IU (IV or IM), initiate uterine massage and bimanual compression, and begin fluid resuscitation—tranexamic acid must be given within 3 hours of birth as effectiveness decreases by 10% for every 15-minute delay. 1, 2

Immediate First-Line Interventions (Within Minutes)

Pharmacological Management

• Administer oxytocin 5-10 IU slowly IV or IM immediately as the first-line prophylactic and therapeutic agent 1, 2, 3
• Follow with maintenance oxytocin infusion: add 10-40 units to 1,000 mL non-hydrating physiologic electrolyte solution, run at rate necessary to control atony (not to exceed 40 IU cumulative dose) 3, 4
• Administer tranexamic acid 1 g IV over 10 minutes within 3 hours of birth—this is critical regardless of PPH etiology (atony, trauma, retained tissue) 1, 2
• A second dose of tranexamic acid 1 g can be given if bleeding continues after 30 minutes or restarts within 24 hours 5, 1, 2

Non-Pharmacological Interventions

• Perform immediate uterine massage and bimanual compression: place fist inside vagina against anterior lower uterine segment with counter-pressure on abdomen 1, 2
• Conduct manual uterine examination with antibiotic prophylaxis 4
• Perform careful visual assessment of lower genital tract for lacerations 4
• Begin fluid resuscitation with physiologic electrolyte solutions 1, 2

Second-Line Management (If Bleeding Persists After 30 Minutes)

Additional Uterotonics

• Administer sulprostone within 30 minutes of PPH diagnosis if oxytocin fails 4
• Methylergonovine 0.2 mg IM can be used, but is contraindicated in hypertensive patients (>10% risk of severe hypertension and vasoconstriction) and should be avoided in asthma due to bronchospasm risk 1, 6
• Carboprost tromethamine (15-methyl PGF2α) IM is an option for refractory uterine atony 7

Mechanical Interventions

• Implement intrauterine balloon tamponade before proceeding to surgery or interventional radiology 1, 2, 4
• Pelvic pressure packing is effective for acute uncontrolled hemorrhage stabilization and can remain for 24 hours 1, 2

Resuscitation Protocol

Blood Product Management

• Initiate massive transfusion protocol if blood loss exceeds 1,500 mL 1, 2
• Transfuse packed RBCs, fresh frozen plasma, and platelets in fixed ratio 1, 2
• Do not delay transfusion waiting for laboratory results in severe bleeding—administer RBC, fibrinogen, and FFP without awaiting labs 1, 4
• Target hemoglobin >8 g/dL and fibrinogen ≥2 g/L during active hemorrhage 1, 4

Essential Supportive Measures

• Maintain normothermia: warm all infusion solutions and blood products; use active skin warming (clotting factors function poorly at lower temperatures) 1, 2, 4
• Administer oxygen in severe PPH 1, 4
• Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL 1, 2

Surgical and Interventional Options (Third-Line)

When to Escalate

• Proceed to invasive treatments if PPH not controlled by pharmacological treatments and intrauterine balloon 4
• Arterial embolization is particularly useful when no single bleeding source is identified—requires hemodynamic stability for transfer 1, 2
• Rule out hemoperitoneum before hospital-to-hospital transfer for embolization 4

Surgical Interventions

• Uterine compression sutures (B-Lynch or similar brace sutures) 1, 2
• Systematic pelvic devascularization including uterine or internal iliac artery ligation 2, 4
• Hysterectomy as final surgical option for uncontrollable PPH 4, 8

Etiology-Specific Management (Four T's Mnemonic)

Tone (Uterine Atony)

• Most common cause—managed with uterotonics and uterine massage as above 9

Trauma (Lacerations, Hematomas, Rupture)

• Careful visual inspection and repair of genital tract lacerations 4, 9
• Address uterine rupture or inversion surgically 2
• Small (<4 cm) subfascial and bladder flap hematomas may not be clinically significant 2

Tissue (Retained Placenta/Products)

• Manual removal of retained placenta with appropriate analgesia and aseptic technique 4, 9
• In out-of-hospital births, do NOT perform manual removal except in severe uncontrolled hemorrhage (due to technical difficulties and lack of adequate analgesia/asepsis) 5
• Surgical evacuation of retained products of conception if needed 2
• Ultrasound can diagnose retained products showing echogenic endometrial mass with vascularity 2

Thrombin (Coagulopathy)

• Obtain coagulation screens as soon as persistent PPH diagnosed 8
• Maintain fibrinogen ≥2 g/L with cryoprecipitate or fibrinogen concentrate 1, 4

Monitoring and Follow-Up

• Continue hemodynamic monitoring for at least 24 hours post-delivery due to significant fluid shifts 1, 2
• Monitor for complications: renal failure, liver failure, infection, Sheehan syndrome 1, 2
• Consider thromboprophylaxis after bleeding controlled, especially with additional VTE risk factors 1
• Early ambulation with elastic support stockings to reduce thromboembolism risk 1

Critical Pitfalls to Avoid

• Never delay tranexamic acid administration—every 15-minute delay reduces effectiveness by 10%, and administration beyond 3 hours may be harmful 1, 2
• Do not delay transfusion waiting for laboratory results in active severe bleeding 1, 4
• Do not use methylergonovine in hypertensive or asthmatic patients 1, 6
• Do not perform manual placental removal in out-of-hospital settings unless hemorrhage is severe and uncontrolled 5
• Avoid hypothermia and acidosis as they impair clotting function 1, 2, 4