NSAIDs Should Be Avoided in Postpartum Hemorrhage Management
NSAIDs have no role in the treatment of postpartum hemorrhage and should be avoided, particularly in women with preeclampsia or acute kidney injury, where they can worsen hypertension and renal function. 1
Why NSAIDs Are Not Used for PPH
Lack of Hemostatic Effect
- NSAIDs do not address the primary mechanisms of postpartum hemorrhage, which are uterine atony (tone), genital tract trauma, retained placental tissue, and coagulopathy 2
- The cornerstone of PPH management relies on uterotonics (oxytocin, tranexamic acid), mechanical interventions, and surgical approaches—none of which involve NSAIDs 3, 4
Potential Harm in the Postpartum Period
- NSAIDs can cause severe hypertension in postpartum women, particularly those with preeclampsia 1
- They should be avoided in women with acute kidney injury, as they can worsen renal function 1
- Alternative analgesics are recommended as first-choice pain management for women with preeclampsia until prospective randomized trials clarify safety 1
Evidence-Based PPH Management Algorithm
First-Line Treatment (Within Minutes of Diagnosis)
- Oxytocin 5-10 IU IV or IM with uterine massage and bimanual compression 3, 4
- Tranexamic acid 1 g IV over 10 minutes if within 3 hours of birth 3, 4, 5
- Manual uterine examination with antibiotic prophylaxis 6
- Careful visual assessment of lower genital tract for trauma 6
Critical Timing Considerations
- Tranexamic acid effectiveness decreases by 10% for every 15 minutes of delay 1, 3, 4
- TXA is contraindicated beyond 3 hours postpartum as it may be potentially harmful 1, 3, 5
- A second 1 g dose of TXA may be given if bleeding continues after 30 minutes or restarts within 24 hours 3, 5
Second-Line Pharmacotherapy (If Bleeding Persists After 30 Minutes)
- Methylergonovine 0.2 mg IM (contraindicated in hypertensive patients) 4
- Rectal misoprostol 800-1000 mcg for active hemorrhage unresponsive to oxytocin 4
- Sulprostone within 30 minutes of PPH diagnosis 6
Mechanical and Invasive Interventions
- Intrauterine balloon tamponade has 79.4-88.2% success rate for uterine atony 1, 3, 4
- Uterine artery embolization when no single bleeding source is identified 4
- Surgical interventions (B-Lynch sutures, arterial ligation, hysterectomy) as definitive measures 3, 4
Common Pitfalls to Avoid
- Do not delay TXA administration—give as soon as PPH is diagnosed, not after waiting for laboratory results 3, 4
- Do not give TXA beyond 3 hours postpartum 1, 3, 5
- Maintain normothermia, as clotting factors function poorly at lower temperatures 4
- Initiate massive transfusion protocol if blood loss exceeds 1,500 mL 4
- Continue hemodynamic monitoring for at least 24 hours after delivery due to significant fluid shifts 3, 4
Pain Management in PPH Patients
For postpartum analgesia in women with preeclampsia or those at risk for complications, use alternative pain relief methods instead of NSAIDs 1. The focus during active PPH is hemostasis, not analgesia—pain control becomes relevant only after bleeding is controlled.
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