What is the management of postpartum hemorrhage (PPH)?

Management of Postpartum Hemorrhage

Administer tranexamic acid 1 g IV over 10 minutes immediately upon diagnosis of PPH (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. 1, 2

Immediate First-Line Pharmacological Management

Tranexamic Acid (Critical Time-Sensitive Intervention)

• TXA 1 g IV over 10 minutes must be given within 3 hours of birth—this is non-negotiable. 1, 2, 3
• Effectiveness decreases by approximately 10% for every 15-minute delay, and administration beyond 3 hours may be harmful rather than beneficial. 1, 2, 3
• Administer TXA in all cases of PPH regardless of etiology (uterine atony, trauma, retained tissue, or coagulopathy). 1, 2
• A second dose of TXA 1 g IV can be given if bleeding continues after 30 minutes or restarts within 24 hours. 1, 2, 3

Oxytocin Administration

• Administer oxytocin 5-10 IU slow IV or IM immediately after delivery of the anterior shoulder or placenta. 4, 1, 2
• The IV route is more effective than IM for PPH prevention and treatment. 5
• For active PPH treatment, use 10-40 units of oxytocin in 1,000 mL of non-hydrating diluent (physiologic electrolyte solution) run at a rate necessary to control uterine atony. 6
• Higher oxytocin doses (up to 80 IU) are associated with a 47% reduction in PPH compared to lower doses (10 IU), with moderate doses (30 IU) showing intermediate benefit. 2, 7

Mechanical Interventions (Sequential Approach)

Immediate Physical Maneuvers

• Initiate uterine massage and bimanual compression immediately upon diagnosis. 1, 2
• These maneuvers should be performed while pharmacological agents are being prepared and administered. 2

Intrauterine Balloon Tamponade

• Implement intrauterine balloon tamponade before proceeding to surgery or interventional radiology. 1, 2
• Success rate is 90% when properly placed, with 79.4-88.2% effectiveness in uterine atony cases. 2
• Pelvic pressure packing can remain in place for 24 hours for acute uncontrolled hemorrhage stabilization. 1

Second-Line Pharmacological Agents

Methylergonovine

• Administer methylergonovine 0.2 mg IM only if oxytocin fails and patient is normotensive. 1, 8
• Methylergonovine is absolutely contraindicated in hypertensive patients (>10% risk of severe vasoconstriction and hypertensive crisis). 1, 2, 3
• Also avoid in women with asthma due to bronchospasm risk. 1

Carboprost Tromethamine

• Use carboprost for postpartum hemorrhage due to uterine atony that has not responded to oxytocin and uterine massage. 9
• Prior treatment should include IV oxytocin and manipulative techniques before carboprost administration. 9

Resuscitation and Blood Product Management

Fluid Resuscitation

• Begin immediate fluid resuscitation with physiologic electrolyte solutions. 1, 2
• Warm all infusion solutions and blood products to maintain normothermia (clotting factors function poorly at lower temperatures). 1

Massive Transfusion Protocol

• Initiate massive transfusion protocol if blood loss exceeds 1,500 mL. 1
• Transfuse packed RBCs, fresh frozen plasma, and platelets in fixed ratio. 1
• Do not delay transfusion waiting for laboratory results in severe bleeding. 1
• Target hemoglobin >8 g/dL and fibrinogen ≥2 g/L during active hemorrhage. 1

Surgical and Interventional Options

Conservative Surgical Interventions

• Uterine compression sutures (B-Lynch or similar brace sutures) can be used to control bleeding when medical management and balloon tamponade fail. 1, 2
• Non-pneumatic antishock garment can be used for temporary stabilization while arranging definitive care. 1, 2

Arterial Embolization

• Arterial embolization is particularly useful when no single bleeding source is identified. 1
• Requires hemodynamic stability for transfer to interventional radiology. 1

Critical Pitfalls to Avoid

Manual Removal of Placenta

• Do not perform manual removal of placenta routinely to reduce PPH risk. 4, 3
• Manual removal should only be performed in cases of severe and uncontrollable PPH, not as a preventive measure. 4, 3
• Spontaneous placental delivery should occur within 30 minutes; retained placenta beyond this increases PPH risk. 3

Time-Sensitive Errors

• Never delay TXA administration—every 15 minutes of delay reduces effectiveness by 10%. 1, 2, 3
• Never administer TXA beyond 3 hours postpartum as it may cause harm. 1, 2, 3

Monitoring and Supportive Care

Hemodynamic Monitoring

• 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
• Monitor for complications including renal failure, liver failure, infection, and Sheehan syndrome. 1

Oxygen and Antibiotics

• Administer oxygen in severe PPH. 1
• Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL. 1

Thromboprophylaxis

• Consider thromboprophylaxis after bleeding is controlled, especially with additional VTE risk factors. 1
• Early ambulation with elastic support stockings can reduce thromboembolism risk. 1

Special Populations

Anticoagulated Patients

• Active management of third stage with uterotonics (oxytocin) is critical, as the primary mechanism of placental bed hemostasis is myometrial contraction, not coagulation. 2
• Switch from oral anticoagulants to LMWH/UFH from 36 weeks gestation. 1
• Discontinue UFH 4-6 hours before planned delivery. 1
• If emergent delivery is required on therapeutic anticoagulation, consider protamine (partially reverses LMWH). 1