What is the management of Postpartum Hemorrhage (PPH)?

Management of Postpartum Hemorrhage

Immediately administer tranexamic acid 1 g IV over 10 minutes alongside oxytocin 5-10 IU (IV or IM), initiate uterine massage and bimanual compression, and begin fluid resuscitation—this must occur within 3 hours of birth as effectiveness decreases by 10% for every 15-minute delay and becomes potentially harmful after 3 hours. 1, 2, 3

Immediate First-Line Management (Within Minutes)

Pharmacological interventions:

• Tranexamic acid 1 g IV over 10 minutes is critical and must be given within 3 hours of birth—delay reduces effectiveness by approximately 10% every 15 minutes, with no benefit and potential harm beyond 3 hours 1, 2, 3
• Oxytocin 5-10 IU administered slowly IV or IM, followed by maintenance infusion not exceeding 40 IU cumulative dose 2, 4, 5
• A second dose of tranexamic acid 1 g IV can be given if bleeding continues after 30 minutes or restarts within 24 hours 2, 3

Mechanical interventions:

• Uterine massage and bimanual compression should be performed immediately 2, 3, 5
• Manual uterine examination with antibiotic prophylaxis to identify retained tissue 5
• Careful visual inspection of the lower genital tract for lacerations, particularly when the uterus is firm (indicating trauma rather than atony as the cause) 1, 6

Resuscitation:

• Begin fluid resuscitation with physiologic electrolyte solutions immediately 2, 3, 4
• Initiate massive transfusion protocol if blood loss exceeds 1,500 mL 2, 3

Second-Line Pharmacological Management (If Bleeding Persists After 30 Minutes)

Uterotonic escalation:

• Carboprost tromethamine (15-methyl PGF2α) 250 mcg IM for refractory uterine atony 7
• Methylergonovine 0.2 mg IM—contraindicated in hypertensive patients (>10% risk of severe hypertension and vasoconstriction) and should be avoided in asthmatic patients due to bronchospasm risk 2, 8

Mechanical and Surgical Interventions (If Pharmacological Management Fails)

Non-surgical mechanical interventions:

• Intrauterine balloon tamponade should be implemented before proceeding to surgery or interventional radiology, with success rates of 79-90% when properly placed 2, 3, 5
• Pelvic pressure packing for acute uncontrolled hemorrhage stabilization, can remain for 24 hours 2, 3
• Non-pneumatic antishock garment for temporary stabilization while arranging definitive care 1

Surgical and interventional options:

• Uterine compression sutures (B-Lynch or similar brace sutures) for persistent bleeding 1, 2
• Arterial embolization is particularly useful when no single bleeding source is identified, but requires hemodynamic stability for transfer 1, 2, 5
• Surgical ligation of uterine/internal iliac arteries if embolization unavailable or unsuccessful 1
• Hysterectomy as final surgical option for uncontrollable PPH 1, 9

Blood Product Management and Transfusion

Transfusion thresholds and targets:

• Do not delay transfusion waiting for laboratory results in severe bleeding 2, 3
• Target hemoglobin >8 g/dL during active hemorrhage 2, 3, 5
• Target fibrinogen ≥2 g/L during active hemorrhage 2, 3, 5
• Transfuse packed RBCs, fresh frozen plasma, and platelets in fixed ratio when massive transfusion protocol initiated 2, 3

Essential Supportive Measures

Critical adjunctive interventions:

• Maintain normothermia by warming all infusion solutions and blood products and using active skin warming—clotting factors function poorly at lower temperatures 2, 5
• Administer oxygen in severe PPH 2, 5
• Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL 2
• Continue hemodynamic monitoring for at least 24 hours post-delivery due to significant fluid shifts 2, 3

Etiology-Specific Management

The "4 T's" approach (Tone, Trauma, Tissue, Thrombin):

• Tone (uterine atony): Accounts for 70-80% of PPH cases; diagnosed by soft, boggy uterus; treated with uterotonic drugs and massage as above 1, 6, 10
• Trauma (lacerations, rupture): Requires careful visual inspection and surgical repair; CT with IV contrast useful for localizing bleeding in hemodynamically stable patients 1, 6, 10
• Tissue (retained products): Ultrasound can diagnose retained products of conception; treatment is curettage if confirmed 1, 6
• Thrombin (coagulopathy): Less common but life-threatening; requires early coagulation screening and correction 1, 10

Imaging Considerations

When to use imaging:

• CT with IV contrast is useful in hemodynamically stable patients to localize bleeding sources, particularly for intra-abdominal hemorrhage 2
• Small (<4 cm) subfascial and bladder flap hematomas may not be clinically significant 2
• A >5 cm bladder flap hematoma should raise suspicion for uterine dehiscence 2
• Ultrasound is appropriate for diagnosing retained products of conception 1, 2

Special Populations

Anticoagulated patients:

• Women with mechanical heart valves should switch from oral anticoagulants to LMWH/UFH from 36 weeks gestation 2, 3
• Discontinue UFH 4-6 hours before planned delivery 2
• If emergent delivery required on therapeutic anticoagulation, consider protamine (partially reverses LMWH) 2
• Women receiving therapeutic-dose LMWH have 1.9-fold increased PPH risk (29.6% vs 17.6%) 6

Critical Pitfalls to Avoid

Time-sensitive errors:

• Delaying tranexamic acid administration beyond 3 hours or waiting to give it—every 15-minute delay reduces effectiveness by 10% and administration beyond 3 hours may be harmful 1, 2, 3
• Delaying blood product transfusion while waiting for laboratory results in active severe bleeding 2, 3

Medication errors:

• Using methylergonovine in hypertensive patients (>10% risk of severe hypertension) 2, 8
• Using methylergonovine in asthmatic patients (bronchospasm risk) 2

Management errors:

• Failing to maintain normothermia and normal pH, which impairs clotting function 2, 5
• Routine manual removal of placenta in non-severe cases 3

Post-Acute Monitoring

Complications surveillance:

• Monitor for renal failure, liver failure, infection, and Sheehan syndrome 2, 3
• Early ambulation with elastic support stockings to reduce thromboembolism risk 2
• Consider thromboprophylaxis after bleeding controlled, especially with additional VTE risk factors 2