Management of Postpartum Hemorrhage
Definition and Recognition
Postpartum hemorrhage is defined as blood loss exceeding 500 mL after vaginal delivery or 1000 mL after cesarean section, or any blood loss causing hemodynamic instability, occurring within 24 hours (primary PPH) or between 24 hours to 6 weeks postpartum (secondary PPH). 1, 2
- PPH accounts for 27% of maternal deaths worldwide and affects 1-5% of all deliveries 1
- The diagnosis should not wait for quantified blood loss—signs of hypovolemia (tachycardia, hypotension, altered mental status) mandate immediate intervention 1
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 with bimanual compression, and begin aggressive fluid resuscitation with crystalloids. 3, 4, 2
Critical Time-Sensitive Actions:
- TXA must be given within 3 hours of birth—effectiveness decreases by 10% for every 15-minute delay, and administration beyond 3 hours may be harmful 3, 4, 2
- A second dose of TXA 1 g IV should be given if bleeding continues after 30 minutes or restarts within 24 hours 3, 2
- TXA reduces bleeding-related mortality and need for laparotomy regardless of PPH etiology (atony, trauma, retained tissue) 3, 4
- Do not delay TXA or transfusion while waiting for laboratory results in active hemorrhage 2
Concurrent Uterotonic Therapy:
- Oxytocin is the first-line uterotonic and more effective than misoprostol with fewer adverse effects 2, 5
- If oxytocin fails, administer methylergonovine 0.2 mg IM—but this is absolutely contraindicated in hypertensive patients (>10% risk of severe vasoconstriction and hypertensive crisis) 3, 2
- Methylergonovine should also be avoided in asthmatic patients due to bronchospasm risk 3
- Carboprost tromethamine (15-methyl PGF2α) 250 mcg IM can be used for refractory uterine atony unresponsive to oxytocin and ergot preparations 6
Identify the Cause Using the "4 T's" Framework
While initiating treatment, simultaneously identify the underlying cause to guide definitive management: 1, 5
1. Tone (Uterine Atony) - Most Common (>75% of cases)
- Diagnosed clinically by palpating a soft, boggy uterus 1, 2
- Treated with uterine massage, bimanual compression, and uterotonics 1
2. Trauma (Lacerations, Rupture, Hematomas)
- Requires careful visual inspection of cervix, vagina, and perineum 2
- Bladder flap hematomas >5 cm should raise suspicion for uterine dehiscence 3
- CT with IV contrast is useful in hemodynamically stable patients to localize intra-abdominal bleeding sources 3, 2
3. Tissue (Retained Placenta/Products of Conception)
- Ultrasound shows echogenic endometrial mass with vascularity 2
- Requires manual removal or surgical evacuation 2
4. Thrombin (Coagulopathy)
- Obtain baseline CBC, coagulation profile, fibrinogen level, and crossmatch 2
- Fibrinogen <2 g/L occurs in 17% of cases with blood loss >2000 mL 4
Escalating Mechanical and Surgical Interventions
If pharmacological management fails, proceed systematically through mechanical and surgical options before considering hysterectomy: 1, 3
Non-Surgical Interventions (Implement Before Surgery):
- Intrauterine balloon tamponade should be the next step after failed medical management 3, 2
- Pelvic pressure packing is effective for acute uncontrolled hemorrhage and can remain for 24 hours 3, 2
- Non-pneumatic antishock garment provides temporary stabilization during transfer 3, 2
Surgical Hierarchy:
- Uterine compression sutures (B-Lynch or brace sutures) for persistent bleeding 3
- Uterine artery embolization is particularly useful when no single bleeding source is identified, but requires hemodynamic stability for transfer to interventional radiology 3, 4, 2
- Uterine or internal iliac artery ligation has decreased efficacy due to collateral circulation and technical difficulty 4
- Hysterectomy is reserved as the absolute last resort when all other measures have failed 4
Resuscitation and Blood Product Management
Initiate massive transfusion protocol if blood loss exceeds 1500 mL: 3, 2
- Transfuse packed RBCs, fresh frozen plasma, and platelets in fixed ratio (typically 1:1:1) 3, 2
- Target hemoglobin >8 g/dL and fibrinogen ≥2 g/L during active hemorrhage 3, 4
- Early fibrinogen replacement with cryoprecipitate or fibrinogen concentrate if levels <2 g/L with ongoing bleeding 4
- Platelet transfusion is rarely needed unless blood loss exceeds 5000 mL or platelet count <75 × 10⁹/L 4
Essential Supportive Measures to Prevent Complications
Maintain normothermia and normal physiology—clotting factors function poorly at lower temperatures: 3, 2
- Warm all infusion solutions and blood products 3
- Use active skin warming devices 3
- Administer supplemental oxygen in severe PPH 3
- Re-dose prophylactic antibiotics if blood loss exceeds 1500 mL 3, 2
- Continue hemodynamic monitoring for at least 24 hours post-delivery due to significant fluid shifts that may precipitate heart failure 3, 2
Post-Acute Monitoring and Complications
Monitor for delayed complications that can occur days to weeks after PPH: 3, 2
- Renal failure, liver failure, and infection 3, 2
- Sheehan syndrome (pituitary necrosis from severe hypotension) 3, 2
- Thromboembolism risk increases after PPH—consider thromboprophylaxis with elastic support stockings and early ambulation once bleeding is controlled 3
Common Pitfalls to Avoid
- Delaying TXA administration—every 15 minutes of delay reduces effectiveness by 10% 3, 4, 2
- Administering methylergonovine to hypertensive patients—this can cause life-threatening hypertensive crisis 3, 2
- Waiting for laboratory results before initiating transfusion in severe bleeding 2
- Failing to maintain normothermia, which impairs coagulation cascade 3, 2
- Small subfascial or bladder flap hematomas (<4 cm) may not be clinically significant and do not require intervention 3, 2
- Proceeding directly to surgery without attempting intrauterine balloon tamponade 3