What are the newest guidelines for postpartum hemorrhage (PPH) management?

Management of Postpartum Hemorrhage: Current Guidelines

Administer tranexamic acid 1 g IV over 10 minutes within 3 hours of birth alongside oxytocin 5-10 IU (IV or IM), initiate uterine massage and bimanual compression, and begin fluid resuscitation with physiologic electrolyte solutions immediately upon diagnosis of PPH. 1, 2

Immediate First-Line Pharmacologic Management

Tranexamic Acid (Critical Time-Sensitive Intervention)

• Tranexamic acid must be given within 3 hours of birth—effectiveness decreases by approximately 10% for every 15-minute delay, and administration beyond 3 hours may be harmful. 1, 2
• Administer 1 g IV at 1 mL/min (over 10 minutes) as soon as PPH is diagnosed, regardless of etiology (uterine atony, trauma, or retained tissue). 1, 2
• A second dose of 1 g IV can be given if bleeding continues after 30 minutes or restarts within 24 hours of the first dose. 1, 2
• The WOMAN trial demonstrated reduced bleeding-related mortality (RR 0.81,95% CI 0.65-1.00) with NNT of 276 when TXA was given within 3 hours. 3

Oxytocin Administration

• Administer oxytocin 5-10 IU slow IV or IM immediately upon PPH diagnosis. 1, 4
• For ongoing bleeding, prepare IV infusion: combine 10 units oxytocin with 1,000 mL physiologic electrolyte solution (10 mU/mL concentration). 4
• Infuse at rate necessary to control uterine atony, not to exceed cumulative dose of 40 IU. 4, 5
• IV route is more effective than IM for PPH treatment. 2

Fluid Resuscitation

• Begin immediate fluid replacement with physiologic electrolyte solutions (not dextrose-containing solutions except under unusual circumstances). 2, 4
• Initiate massive transfusion protocol if blood loss exceeds 1,500 mL. 1

Second-Line Pharmacologic Agents

When Oxytocin Fails (Within 30 Minutes)

• Carboprost tromethamine (prostaglandin F2α) 250 mcg IM is the preferred second-line agent for uterine atony unresponsive to oxytocin. 6
• Carboprost should be used after failure of oxytocin and before proceeding to mechanical interventions. 6

Methylergonovine Considerations

• Methylergonovine 0.2 mg IM is absolutely contraindicated in hypertensive patients (>10% risk of severe vasoconstriction and hypertension). 1, 2
• Also contraindicated in women with asthma due to bronchospasm risk. 1
• Only use if patient is normotensive and has no respiratory disease. 7

Mechanical Interventions (Sequential Approach)

Immediate Manual Techniques

• Perform uterine massage and bimanual compression simultaneously with pharmacologic management. 1, 5
• Conduct manual uterine examination with antibiotic prophylaxis to identify retained tissue. 5
• Perform careful visual assessment of lower genital tract for lacerations requiring repair. 5

Intrauterine Balloon Tamponade

• Implement intrauterine balloon tamponade if pharmacologic management fails, before proceeding to surgery or interventional radiology. 1, 2
• Success rate of 79.4-88.2% when properly placed for uterine atony. 2
• Balloon can remain in place for up to 24 hours. 1

Alternative Mechanical Measures

• Pelvic pressure packing is effective for acute uncontrolled hemorrhage stabilization. 1
• Non-pneumatic antishock garment can provide temporary stabilization while arranging definitive care. 1
• External aortic compression may be used as temporizing measure. 2

Blood Product Management

Transfusion Thresholds and Targets

• Do not delay transfusion waiting for laboratory results in severe bleeding—administer RBCs, fibrinogen, and FFP based on clinical assessment. 1, 5
• Target hemoglobin >8 g/dL during active hemorrhage. 1, 5
• Target fibrinogen ≥2 g/L during active hemorrhage. 1, 5
• Transfuse packed RBCs, fresh frozen plasma, and platelets in fixed ratio per massive transfusion protocol. 1

Surgical and Interventional Radiology Options

When Conservative Measures Fail

• Uterine compression sutures (B-Lynch or similar brace sutures) can control bleeding when medical and balloon tamponade fail. 1
• Arterial embolization is particularly useful when no single bleeding source is identified but requires hemodynamic stability for transfer. 1, 2
• Rule out hemoperitoneum before hospital-to-hospital transfer for embolization. 5
• Stepwise uterine devascularization or hypogastric artery ligation are surgical options, though embolization is increasingly preferred. 5, 8

Essential Supportive Measures

Temperature and Oxygenation Management

• Maintain normothermia: warm all infusion solutions and blood products; use active skin warming (clotting factors function poorly at lower temperatures). 1, 5
• Administer supplemental oxygen in severe PPH. 1, 5

Antibiotic Coverage

• Administer antibiotic prophylaxis with manual uterine examination. 5
• Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL. 1

Monitoring Duration

• 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

Special Populations

Anticoagulated Patients

• Switch from oral anticoagulants to LMWH/UFH from 36 weeks gestation in patients with mechanical heart valves. 1
• Discontinue UFH 4-6 hours before planned delivery. 1
• If emergent delivery required on therapeutic anticoagulation, consider protamine (partially reverses LMWH). 1
• Cesarean delivery is preferred to reduce fetal intracranial hemorrhage risk. 1

Manual Placental Removal

• Manual removal of placenta should NOT be routinely performed outside specialized structures except in severe and uncontrollable hemorrhage. 3, 2
• Risk of PPH >500 mL increases when spontaneous placental delivery occurs >30 minutes after fetal expulsion (RR 5.94). 3
• If manual removal necessary, ensure adequate analgesia, aseptic conditions, and administer tranexamic acid. 3

Diagnostic Imaging Considerations

CT Imaging for Stable Patients

• CT with IV contrast is useful in hemodynamically stable patients to localize bleeding sources, particularly for intra-abdominal hemorrhage. 1
• Small (<4 cm) subfascial and bladder flap hematomas may not be clinically significant. 1
• Bladder flap hematoma >5 cm should raise suspicion for uterine dehiscence. 1
• Ultrasound can diagnose retained products of conception. 1

Post-Hemorrhage Complications Monitoring

• Monitor for renal failure, liver failure, infection, and Sheehan syndrome. 1
• Consider thromboprophylaxis after bleeding is controlled, especially with additional VTE risk factors. 1
• Early ambulation with elastic support stockings reduces thromboembolism risk. 1

Common Pitfalls to Avoid

• Never delay TXA administration beyond 3 hours—this is the single most critical time-sensitive intervention. 1, 2
• Do not use methylergonovine in hypertensive or asthmatic patients. 1, 2
• Do not exceed 40 IU cumulative oxytocin dose. 4, 5
• Do not perform routine manual placental removal in out-of-hospital births. 3
• Do not wait for laboratory results before initiating transfusion in severe bleeding. 1, 5