What is the immediate management of Post Partum Hemorrhage (PPH)?

Immediate Management of Postpartum Hemorrhage

Administer tranexamic acid 1 g IV over 10 minutes 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

Time-Critical Pharmacological Interventions

Tranexamic Acid (TXA) - First Priority

• Give TXA 1 g IV over 10 minutes immediately upon diagnosis of PPH, regardless of the cause (uterine atony, trauma, or retained tissue). 2, 1
• TXA must be administered within 3 hours of birth—effectiveness decreases by approximately 10% for every 15 minutes of delay, and administration beyond 3 hours may be harmful. 2, 1, 3
• A second dose of TXA 1 g IV can be given if bleeding continues after 30 minutes or restarts within 24 hours. 2, 1, 3
• The number needed to treat is 276 to prevent one bleeding-related death. 3

Oxytocin - Simultaneous Administration

• Administer oxytocin 5-10 IU slow IV or IM immediately; the IV route is more effective than IM for PPH prevention. 2, 4
• For ongoing hemorrhage, escalate to 10-40 units of oxytocin in 1,000 mL of physiologic electrolyte solution, infused at a rate necessary to control uterine atony. 4
• Higher oxytocin doses (up to 80 IU) are associated with a 47% reduction in PPH compared to lower doses (10 IU). 2

Immediate Physical Maneuvers

• Initiate uterine massage and bimanual compression immediately. 1
• Bimanual compression involves placing one fist in the anterior vaginal fornix against the anterior uterine wall while the other hand compresses the posterior uterus through the abdomen. 5
• External aortic compression can be used for temporary stabilization while arranging definitive care. 2

Fluid Resuscitation and Blood Product Management

• Begin IV fluid resuscitation with physiologic electrolyte solutions immediately. 2, 1
• Initiate massive transfusion protocol if blood loss exceeds 1,500 mL. 1
• Transfuse packed RBCs, fresh frozen plasma, and platelets in fixed ratio—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

Second-Line Pharmacological Agents

When Oxytocin Fails

• Carboprost (Hemabate) 250 mcg IM deep injection is indicated for PPH due to uterine atony unresponsive to oxytocin. 6
• The majority of successful cases (73%) respond to a single injection; additional doses can be given at 15-90 minute intervals. 6
• Total dose should not exceed 2 mg (8 doses). 6

Contraindications and Cautions

• Methylergonovine 0.2 mg IM is contraindicated in hypertensive patients (>10% risk of severe vasoconstriction and hypertensive crisis). 2, 1, 3
• Methylergonovine should also be avoided in women with asthma due to bronchospasm risk. 1
• Prostaglandin F analogues are contraindicated when an increase in pulmonary artery pressure is undesirable. 2

Mechanical Interventions - Sequential Escalation

Intrauterine Balloon Tamponade

• Implement intrauterine balloon tamponade before proceeding to surgery or interventional radiology, with a success rate of 90% when properly placed. 2, 1
• Success rates range from 79.4% to 88.2% in uterine atony cases. 2

Uterine Packing

• Pelvic pressure packing is effective for acute uncontrolled hemorrhage stabilization and can remain for 24 hours. 1

Non-Pneumatic Antishock Garment

• Can be used for temporary stabilization while arranging definitive care. 2, 1

Identifying the Cause - The "Four T's"

• Tone (uterine atony): Most common cause (>75% of cases); treat with uterotonics and uterine massage. 1, 5
• Trauma (lacerations, rupture): Requires careful visual inspection and surgical repair; CT with IV contrast is useful in hemodynamically stable patients to localize bleeding. 1
• Tissue (retained placenta/products): Manual removal should not be performed routinely except in severe, uncontrollable PPH; ultrasound can diagnose retained products. 7, 1, 3
• Thrombin (coagulopathy): Requires correction with blood products and factor replacement. 5

Surgical Interventions - When Conservative Measures Fail

• Uterine compression sutures (B-Lynch or similar brace sutures) can control bleeding when medical and balloon tamponade measures fail. 1
• Arterial embolization is particularly useful when no single bleeding source is identified, but requires hemodynamic stability for transfer. 1
• Systematic pelvic devascularization (uterine artery ligation, internal iliac artery ligation) may be attempted before hysterectomy. 8
• Subtotal or total abdominal hysterectomy is the definitive surgical intervention when all other measures fail. 8

Essential Supportive Measures

• Maintain normothermia: Warm all infusion solutions and blood products; use active skin warming, as clotting factors function poorly at lower temperatures. 1
• Administer supplemental oxygen in severe PPH. 1
• Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL. 1
• 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. 2, 1

Critical Pitfalls to Avoid

• Do not delay TXA administration—every 15 minutes of delay reduces effectiveness by 10%, and administration beyond 3 hours may cause harm. 2, 1, 3
• Do not perform manual removal of placenta before 30 minutes have elapsed unless there is severe, uncontrollable hemorrhage, as this increases infection and hemorrhage risk. 7, 3
• Do not use methylergonovine in hypertensive patients or those with asthma. 2, 1, 3
• Do not delay blood transfusion waiting for laboratory results in severe bleeding. 1

Special Populations

Anticoagulated Patients

• Active management with uterotonics (oxytocin) is critical, as the primary mechanism of placental bed hemostasis is myometrial contraction, not coagulation. 2
• If emergent delivery is required on therapeutic anticoagulation, consider protamine (partially reverses LMWH). 1
• Caesarean delivery is preferred to reduce fetal intracranial hemorrhage risk. 1

Post-Hemorrhage Monitoring

• Monitor for complications: renal failure, liver failure, infection, Sheehan syndrome. 1
• Consider thromboprophylaxis after bleeding is controlled, especially with additional VTE risk factors. 1
• Early ambulation with elastic support stockings can reduce thromboembolism risk. 1