What are the first-line and second-line treatments for postpartum hemorrhage (PPH) according to the World Health Organization (WHO) guidelines?

WHO 2025 Guidelines for Postpartum Hemorrhage Management

First-Line Treatment

The WHO strongly recommends early intravenous tranexamic acid (1 g over 10 minutes) within 3 hours of birth, combined with oxytocin (5-10 IU IV or IM), as first-line treatment for all women with clinically diagnosed postpartum hemorrhage. 1, 2

Tranexamic Acid Administration

• Administer 1 g IV over 10 minutes as soon as PPH is diagnosed 2, 3
• Must be given within 3 hours of birth - effectiveness decreases by 10% for every 15 minutes of delay 1, 2, 3
• Do NOT administer beyond 3 hours postpartum - evidence suggests potential harm rather than benefit 1, 2, 3
• A second 1 g dose can be given if bleeding continues after 30 minutes or restarts within 24 hours 2, 4
• Use in all cases of PPH regardless of etiology (uterine atony, genital tract trauma, or other causes) 2
• Number needed to treat: 276 to prevent one bleeding-related death 4

Oxytocin Administration

• Administer 5-10 IU slow IV or IM immediately upon PPH diagnosis 2, 3, 5
• Follow with maintenance infusion of 10-40 IU in 1000 mL at a rate necessary to control atony, not exceeding 40 IU cumulative dose 3, 5
• Higher doses (up to 80 IU total) are associated with 47% reduction in PPH compared to lower doses 2
• Can be given as IV bolus (5-10 IU over 1-2 minutes) for active hemorrhage 5

Critical Timing Considerations

• Tranexamic acid is time-critical: loses 10% effectiveness every 15 minutes after birth 1, 2, 3
• Absolute contraindication: TXA beyond 3 hours postpartum 1, 2, 3, 4
• At 24 hours postpartum, TXA is contraindicated if not already administered 3

Second-Line Pharmacotherapy

If bleeding persists after oxytocin and tranexamic acid, proceed sequentially through second-line uterotonics within 30 minutes of PPH diagnosis. 3, 6

Methylergonovine

• Dose: 0.2 mg IM 3, 7
• Absolute contraindication in hypertensive patients - risk of severe vasoconstriction and hypertensive crisis 2, 3, 4
• May increase nausea, vomiting, and diarrhea 8

Misoprostol (Rectal)

• Dose: 800-1000 mcg rectally for active hemorrhage unresponsive to oxytocin 3, 4
• Achieves sustained uterine contraction within 3 minutes 3
• Hemorrhage control rate of 63% within 10 minutes 3
• May increase nausea, vomiting, fever, and diarrhea 8

Carboprost (Prostaglandin F2α)

• First-line prostaglandin for PPH treatment despite side effects 9
• Do not delay administration while waiting for laboratory results during active hemorrhage 3

Mechanical Interventions

If pharmacotherapy fails, proceed to intrauterine balloon tamponade before surgical intervention. 2, 3

Intrauterine Balloon Tamponade

• Success rate: 79.4-88.2% for uterine atony 2, 3
• Implement after failure of uterotonics but before interventional radiology or surgery 2
• Can temporarily control active PPH while preparing for definitive intervention 10

Other Non-Surgical Interventions

• Bimanual uterine compression 2, 3
• Non-pneumatic antishock garment 2
• External aortic compression 2

Surgical and Interventional Procedures

When conservative measures fail, proceed to definitive interventions based on available resources and patient stability. 3, 10

Uterine Artery Embolization

• Particularly useful when no single bleeding source is identified 3
• Hospital-to-hospital transfer possible if hemoperitoneum ruled out and patient hemodynamically stable 6

Surgical Options

• Uterine compression sutures (B-Lynch or similar) 3
• Arterial ligation 2
• Hysterectomy as last resort 2
• Sequential approach: start with least invasive, progress as needed 2, 4

Supportive Care Requirements

Fluid Resuscitation

• Initiate for PPH persistent after first-line uterotonics or with clinical signs of severity 6
• Use physiologic electrolyte solutions 2, 5
• Maintain normothermia - clotting factors function poorly at lower temperatures 3
• Warm infusion solutions and blood products 6

Transfusion Thresholds

• Maintain hemoglobin >8 g/dL 6
• Maintain fibrinogen ≥2 g/L during active hemorrhage 6
• May administer RBC, fibrinogen, and FFP without awaiting laboratory results 6
• Initiate massive transfusion protocol if blood loss exceeds 1500 mL 3

Additional Measures

• Administer oxygen in severe PPH 6
• Manual uterine examination with antibiotic prophylaxis 6
• Re-dose prophylactic antibiotics if blood loss exceeds 1500 mL 3
• Continue hemodynamic monitoring for at least 24 hours after delivery 2, 3

Common Pitfalls to Avoid

• Never delay TXA administration - every 15 minutes reduces effectiveness by 10% 1, 2, 3
• Never give TXA beyond 3 hours postpartum - potentially harmful 1, 2, 3
• Never use methylergonovine in hypertensive patients - risk of hypertensive crisis 2, 3, 4
• Never delay carboprost while awaiting labs during active hemorrhage 3
• Never perform routine manual placental removal before 30 minutes - increases infection and hemorrhage risk 3, 4
• Avoid visual estimation of blood loss - use clinical markers (signs/symptoms) instead 10

Facility Requirements

• All facilities providing emergency obstetric care must have TXA readily available 1
• Necessary supplies and trained staff for safe IV infusion 1, 2
• Regularly checked PPH emergency equipment tray 10
• Availability of uterotonic agents in all birth settings 4