What is the management for postpartum hemorrhage (PPH) after a normal vaginal birth in a patient induced for gestational hypertension?

Management of Postpartum Hemorrhage After Vaginal Delivery in Gestational Hypertension

For postpartum hemorrhage following vaginal delivery in a patient with gestational hypertension, immediately initiate active management with oxytocin, measure blood loss directly, and withhold FFP until 4 units of RBCs have been transfused unless early coagulopathy is confirmed on testing. 1

Immediate Recognition and Initial Response

Abnormal bleeding is defined as >500 mL after vaginal delivery, and this threshold should trigger immediate escalation of care 1. Direct measurement of blood loss through systematic weighing of blood-soaked pads is critical, as visual estimation is notoriously unreliable and correlates poorly with actual hemoglobin drop 1.

Multidisciplinary Team Activation

As soon as the 500 mL threshold is crossed:

• Immediately summon the obstetrician, anesthetist, and senior midwife to attend the patient 1
• Obtain blood samples for: full blood count (hemoglobin), coagulation studies, group and screen, and venous blood gas for rapid hemoglobin measurement and lactate (>2 mmol/L indicates shock) 1

Uterotonic Management

Administer tranexamic acid immediately when PPH is identified (>500 mL after vaginal delivery), as it reduces total blood loss 1.

For uterotonic therapy:

• Oxytocin is the first-line agent: 10-40 units added to 1,000 mL of non-hydrating diluent, run at a rate necessary to control uterine atony 2
• Avoid methylergonovine in this hypertensive patient due to vasoconstrictive effects and risk of worsening hypertension 3
• Active management of the third stage with uterotonics minimizes trauma-related bleeding 1

Blood Product Transfusion Strategy

The key distinction for PPH associated with atony or trauma (most common after vaginal delivery) is that early coagulopathy is unlikely unless diagnosis is delayed 1. This differs critically from abruption, amniotic fluid embolus, or severe pre-eclampsia, which cause early consumptive coagulopathy 1.

Transfusion Algorithm for Atonic/Traumatic PPH:

• Withhold FFP until 4 units of RBCs have been given if coagulation tests are unknown and the bleeding is from atony or trauma 1
• After 4 units of RBC without coagulation results available and ongoing bleeding: infuse 4 units of FFP and maintain 1:1 ratio of RBC:FFP until haemostatic test results are available 1
• Protocol-led FFP use will lead to excessive transfusion in most atonic/traumatic PPH cases 1

Fibrinogen Monitoring and Replacement:

Hypofibrinogenaemia is a critical predictor of ongoing PPH 1. Normal pregnancy fibrinogen is 4-6 g/L:

• Laboratory Clauss fibrinogen <3 g/L, especially <2 g/L with ongoing bleeding, predicts progression to major obstetric hemorrhage 1
• Replace with cryoprecipitate or fibrinogen concentrate when fibrinogen is low and bleeding continues 1
• A recent feasibility trial supports early cryoprecipitate use before FFP in first-issued hemorrhage packs, though confirmatory data are needed 1

Platelet Transfusion:

Platelet transfusion is rarely required unless:

• PPH exceeds 5,000 mL, OR
• Platelet count is <100 × 10⁹/L from another cause prior to PPH 1
• Transfuse platelets when count is <75 × 10⁹/L 1

Point-of-Care Testing

Laboratory testing is often too slow during obstetric hemorrhage; point-of-care (POC) testing is preferred 1. Viscoelastic hemostatic assays (VHAs) are increasingly used across UK maternity units:

• Focus interpretation on the fibrinogen assay 1
• Prioritize fibrinogen replacement with concentrate or cryoprecipitate 1
• Hyperfibrinolysis is common in early PPH, supporting tranexamic acid use 1
• Repeat testing if bleeding is ongoing; withhold blood components if bleeding has stopped 1

Resuscitation Principles

Prevent and treat the lethal triad during resuscitation 1:

• Hypothermia: Maintain temperature >36°C, as clotting factors function poorly when cold 3
• Acidosis: Avoid acidosis, which impairs coagulation 3
• Hypocalcemia: Aim for ionized calcium >1.0 mmol/L 1

Special Considerations for Gestational Hypertension

This patient's hypertensive disorder increases her PPH risk 4. Women with preeclampsia with severe features have a 52% increased risk of composite maternal hemorrhagic outcomes 4. However, gestational hypertension without severe features carries lower risk than severe preeclampsia 4.

Blood Pressure Management During PPH:

• Continue antihypertensive treatment during active bleeding to keep systolic BP <160 mmHg and diastolic BP <110 mmHg 1
• Avoid NSAIDs for postpartum analgesia in hypertensive women, especially with renal involvement, as they worsen hypertension 5

Critical Pitfalls to Avoid

• Do not rely on visual estimation of blood loss—systematic weighing is essential 1
• Do not give FFP prematurely in atonic/traumatic PPH without coagulation abnormalities, as this leads to overtransfusion 1
• Do not use methylergonovine for uterine atony in hypertensive patients 3
• Do not resuscitate with crystalloid alone—use blood products to avoid dilutional coagulopathy 3
• Do not delay recognition—early coagulopathy can occur unpredictably, making monitoring essential 1

Monitoring and Escalation

Continuous monitoring is essential as coagulopathy is unpredictable and etiology may not be clear at PPH onset 1. If bleeding exceeds 1,500-2,000 mL or remains uncontrolled despite initial measures, prepare for potential surgical intervention and consider ICU-level care 5, 3.