What are the guidelines for managing postpartum hemorrhage (PPH)?

Management of Postpartum Hemorrhage

Definition and Initial Recognition

Postpartum hemorrhage is defined as blood loss ≥500 mL after vaginal delivery or ≥1000 mL after cesarean section, or any blood loss sufficient to compromise hemodynamic stability. 1

Immediate First-Line Management (Within Minutes)

Administer intravenous tranexamic acid 1 g over 10 minutes PLUS oxytocin 5-10 IU (IV or IM) immediately upon diagnosis of PPH. 1, 2

• The 3-hour window for tranexamic acid is critical: effectiveness decreases by 10% for every 15-minute delay, and administration beyond 3 hours may be harmful rather than beneficial 3, 1, 2
• Tranexamic acid should be given in ALL cases of PPH regardless of etiology—whether due to uterine atony, genital tract trauma, or retained tissue 3, 1
• A second dose of tranexamic acid 1 g IV can be administered if bleeding continues after 30 minutes or restarts within 24 hours 3, 1, 2

Intravenous oxytocin is superior to intramuscular administration for PPH prevention and treatment, with lower rates of blood loss, PPH ≥500 mL, severe PPH ≥1000 mL, and blood transfusion requirements 4

Concurrent Initial Interventions

• Perform immediate uterine massage and bimanual compression 2, 5
• Begin fluid resuscitation with physiologic electrolyte solutions 1, 2
• Administer prophylactic antibiotics before manual uterine examination 5
• Conduct manual uterine examination to identify retained tissue 5
• Perform careful visual assessment of the lower genital tract for lacerations 5
• Administer supplemental oxygen 2, 5
• Maintain normothermia by warming all infusion solutions, blood products, and using active skin warming (clotting factors function poorly at lower temperatures) 2, 5

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

If oxytocin fails to control bleeding, administer sulprostone within 30 minutes of PPH diagnosis. 5

Alternative Uterotonics

• Carboprost (Hemabate): Indicated for postpartum hemorrhage due to uterine atony unresponsive to conventional methods, has resulted in cessation of life-threatening bleeding and avoidance of emergency surgical intervention 6
• Methylergonovine (Methergine) 0.2 mg IM: Indicated for postpartum atony and hemorrhage 7, but absolutely contraindicated in hypertensive patients due to >10% risk of severe vasoconstriction and hypertension 1, 2
• Methylergonovine should also be avoided in women with asthma due to bronchospasm risk 2
• Misoprostol is less effective than oxytocin with more adverse effects 8

Mechanical Interventions (Before Surgery)

Implement intrauterine balloon tamponade if pharmacological management fails and before proceeding to surgery or interventional radiology. 2, 5

• Pelvic pressure packing is effective for acute uncontrolled hemorrhage stabilization and can remain in place for 24 hours 2
• Non-pneumatic antishock garment can provide temporary stabilization while arranging definitive care 1, 2
• External aortic compression may be used as a temporizing measure 1

Resuscitation and Blood Product Management

Initiate massive transfusion protocol if blood loss exceeds 1,500 mL. 2, 8

• Transfuse packed RBCs, fresh frozen plasma, and platelets in fixed ratios 2
• Do not delay transfusion waiting for laboratory results during severe bleeding 2, 5
• Target hemoglobin >8 g/dL during active hemorrhage 2, 5
• Target fibrinogen ≥2 g/L during active hemorrhage 2, 5
• Fibrinogen and FFP may be administered without awaiting laboratory results 5

Surgical and Interventional Radiology Options

If PPH is not controlled by pharmacological treatments and intrauterine balloon tamponade, proceed to arterial embolization or surgery. 5

Arterial Embolization

• Particularly useful when no single bleeding source is identified 2
• Requires hemodynamic stability for transfer 2
• Hospital-to-hospital transfer for embolization is possible once hemoperitoneum is ruled out and if hemodynamic condition allows 5

Surgical Interventions (in order of invasiveness)

• Uterine compression sutures (B-Lynch or similar brace sutures) 1, 2
• Systematic pelvic devascularization/arterial ligation 1, 9
• Subtotal or total abdominal hysterectomy 9
• No specific conservative surgical technique is favored over another 5

Post-Hemorrhage Monitoring

Continue hemodynamic monitoring for at least 24 hours post-delivery due to significant fluid shifts that may precipitate heart failure in women with structural heart disease 1, 2

• Monitor for complications: renal failure, liver failure, infection, Sheehan syndrome 2
• Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL 2
• Consider thromboprophylaxis after bleeding is controlled, especially with additional VTE risk factors 2
• Early ambulation with elastic support stockings can reduce thromboembolism risk 2

Special Populations

Anticoagulated Patients with Mechanical Heart Valves

• Switch from oral anticoagulants to LMWH/UFH from 36 weeks gestation 2
• Discontinue UFH 4-6 hours before planned delivery 2
• If emergent delivery required on therapeutic anticoagulation, consider protamine (partially reverses LMWH) 2
• Cesarean delivery is preferred to reduce fetal intracranial hemorrhage risk 2

Hypertensive Patients

• Avoid methylergonovine due to severe vasoconstriction risk 1, 2
• Prostaglandin F analogues should not be used if increased pulmonary artery pressure is undesirable 1

Critical Pitfalls to Avoid

• Do not perform manual removal of placenta routinely—only in cases of severe and uncontrollable PPH 3, 2
• Do not delay tranexamic acid administration—every 15 minutes of delay reduces effectiveness by 10% 3, 1
• Do not give tranexamic acid beyond 3 hours after birth—it may be harmful 3, 1, 2
• Do not use intramuscular oxytocin when IV route is available—IV is more effective 4
• Routine episiotomy does not reduce PPH risk and should be avoided 3, 8