What is the management of postpartum hemorrhage (PPH)?

Management of Postpartum Hemorrhage

Immediate First-Line Management (Within Minutes)

Administer tranexamic acid 1 g IV over 10 minutes IMMEDIATELY alongside oxytocin 5-10 IU (IV or IM), initiate uterine massage and bimanual compression, and begin aggressive fluid resuscitation with physiologic electrolyte solutions. 1

Critical Time-Sensitive Actions

• Tranexamic acid MUST be given within 3 hours of birth—effectiveness decreases by approximately 10% for every 15 minutes of delay, and administration beyond 3 hours may be harmful. 1, 2
• TXA should be administered in ALL cases of PPH regardless of etiology (uterine atony, trauma, retained tissue). 1, 2
• A second dose of TXA 1 g IV can be given if bleeding continues after 30 minutes or restarts within 24 hours. 3, 1, 2
• TXA is contraindicated only in women with a known thromboembolic event during pregnancy. 3

Oxytocin Administration

• Administer oxytocin 5-10 IU slow IV or IM immediately postpartum. 3, 1
• For ongoing bleeding, add 10-40 units of oxytocin to 1,000 mL of non-hydrating diluent and run at a rate necessary to control uterine atony, not to exceed a cumulative dose of 40 IU. 4, 5
• The IV route is more effective than IM for PPH prevention. 2

Non-Pharmacological Interventions

• Perform uterine massage and bimanual compression immediately (one fist inside the vagina against the anterior lower uterine segment with counter-pressure on the abdomen). 3, 1
• Conduct manual uterine examination with antibiotic prophylaxis and careful visual assessment of the lower genital tract. 5
• Ensure bladder emptying to optimize uterine contraction. 5

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

• Administer sulprostone within 30 minutes of PPH diagnosis if oxytocin fails to control bleeding. 5
• Sulprostone requires close clinical surveillance with continuous monitoring (ECG, non-invasive blood pressure, pulse oximetry). 6

Alternative Uterotonics

• Carboprost tromethamine (15-methyl PGF2α) is indicated for postpartum hemorrhage due to uterine atony which has not responded to conventional methods, including oxytocin and uterine massage. 7
• Methylergonovine 0.2 mg IM is CONTRAINDICATED in hypertensive patients (>10% risk of severe vasoconstriction and hypertension). 1, 2
• Methylergonovine should also be avoided in women with asthma due to bronchospasm risk. 1

Resuscitation and Transfusion Protocol

Fluid and Blood Product Management

• Initiate massive transfusion protocol if blood loss exceeds 1,500 mL. 3, 1
• Do NOT delay transfusion waiting for laboratory results in severe bleeding—administer RBC, fibrinogen, and FFP without awaiting laboratory confirmation. 3, 5
• Transfuse packed RBCs, fresh frozen plasma, and platelets in a fixed ratio. 3
• Target hemoglobin >8 g/dL and fibrinogen ≥2 g/L during active hemorrhage. 1, 5

Essential Supportive Measures

• Maintain normothermia: warm ALL infusion solutions and blood products; use active skin warming (clotting factors function poorly at lower temperatures). 3, 5
• Administer oxygen in severe PPH. 1, 5
• Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL. 3, 1

Mechanical Interventions (If Pharmacological Management Fails)

• Implement intrauterine balloon tamponade before proceeding to surgery or interventional radiology. 1, 2
• Pelvic pressure packing is effective for acute uncontrolled hemorrhage stabilization and may remain for 24 hours. 3, 1
• Non-pneumatic antishock garment can be used for temporary stabilization while arranging definitive care. 3, 2

Surgical and Interventional Radiology Options

When to Escalate

• If bleeding is not controlled by pharmacological treatments and intrauterine balloon within 30 minutes, proceed to invasive treatments. 6, 5
• Arterial embolization is particularly useful when no single bleeding source is identified, but requires hemodynamic stability for transfer. 1, 5
• Rule out hemoperitoneum before hospital-to-hospital transfer for embolization. 5

Surgical Interventions

• Uterine compression sutures (B-Lynch or similar brace sutures) can control bleeding. 1, 2
• Systematic pelvic devascularization, including uterine or internal iliac artery ligation, may be considered. 3, 2
• Hysterectomy should be considered as a last resort if bleeding continues despite all other measures. 2

Etiology-Specific Management

The Four T's Approach

• Tone (Uterine Atony): Most common cause (>75% of cases)—treated with uterotonic drugs and uterine massage. 8, 9
• Trauma (Lacerations, Rupture): Requires careful visual inspection and surgical repair; CT with IV contrast can localize bleeding in hemodynamically stable patients. 8, 3
• Tissue (Retained Placenta/Products): Manual removal or surgical evacuation; ultrasound shows echogenic endometrial mass with vascularity. 3, 9
• Thrombin (Coagulopathy): Correct with FFP, cryoprecipitate, and platelets; maintain fibrinogen ≥2 g/L. 1, 5

Imaging Considerations

• CT with IV contrast is useful in hemodynamically stable patients to localize bleeding sources, particularly for intra-abdominal hemorrhage. 8, 3
• Small (<4 cm) subfascial and bladder flap hematomas may not be clinically significant. 8, 3
• Ultrasound can diagnose retained products of conception. 3
• A >5 cm bladder flap hematoma should raise suspicion for uterine dehiscence. 8

Post-Acute Monitoring and Complications

• 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, and Sheehan syndrome. 3, 1
• Consider thromboprophylaxis after bleeding is controlled, especially with additional VTE risk factors; early ambulation with elastic support stockings reduces thromboembolism risk. 1

Critical Pitfalls to Avoid

• Delaying TXA administration is the single most important error—every 15-minute delay reduces effectiveness by 10%. 1, 2
• Never delay treatment for active hemorrhage while waiting for laboratory results. 3, 5
• Failing to maintain normothermia and normal pH impairs clotting. 3, 5
• Do not administer methylergonovine to hypertensive patients. 1, 2
• Do not interpret hypodense edema at the cesarean incision site as dehiscence in the first postpartum week. 8