What is the management approach for a postpartum woman, likely with a history of pregnancy complications or risk factors for hemorrhage, presenting with postpartum hemorrhage?

Management of Postpartum Hemorrhage

Immediate First-Line Actions (Within Minutes of Recognition)

Administer tranexamic acid 1 g IV over 10 minutes immediately upon recognizing PPH, alongside oxytocin 5-10 IU (IV or IM), initiate uterine massage and bimanual compression, and begin aggressive fluid resuscitation with crystalloid solutions. 1, 2

Critical Time-Sensitive Interventions

• Tranexamic acid MUST be given within 3 hours of birth—effectiveness decreases by approximately 10% for every 15-minute delay, and administration beyond 3 hours may cause harm rather than benefit 1, 2
• Give TXA 1 g IV over 10 minutes (at 1 mL/min) regardless of whether bleeding is from uterine atony, genital tract trauma, or other causes 1
• Administer a second 1 g dose if bleeding continues after 30 minutes or restarts within 24 hours of the first dose 1, 2
• Simultaneously give oxytocin 5-10 IU by slow IV push or IM injection, followed by continuous infusion up to a maximum cumulative dose of 40 IU 3, 4

Immediate Physical Maneuvers

• Perform uterine massage and bimanual uterine compression immediately 2, 4
• Conduct manual uterine examination with antibiotic prophylaxis to identify retained placental tissue 4
• Perform careful visual inspection of the lower genital tract for lacerations requiring repair 4

Resuscitation Protocol

Fluid and Blood Product Management

• Initiate two large-bore IV lines and begin rapid crystalloid infusion with physiologic electrolyte solutions 1, 2
• Do NOT delay blood product transfusion while waiting for laboratory results in active severe hemorrhage 2, 5
• Transfuse packed RBCs, fresh frozen plasma, and platelets in a 1:1:1 to 1:2:4 ratio when blood loss exceeds 1,500 mL or massive transfusion protocol is activated 6, 2
• Target hemoglobin >8 g/dL during active bleeding 2, 4
• Maintain fibrinogen ≥2 g/L (200 mg/dL)—hypofibrinogenemia is the strongest predictor of severe PPH 6, 4
• Administer cryoprecipitate or fibrinogen concentrate when fibrinogen falls below 200 mg/dL; each unit of cryoprecipitate increases fibrinogen by 10-15 mg/dL 6

Critical Supportive Measures

• Maintain core temperature >36°C by warming all IV fluids and blood products and using active skin warming devices—coagulation factors function poorly in hypothermia 5, 4
• Administer supplemental oxygen to all women with severe PPH 4
• Avoid acidosis, as this also impairs coagulation 5

Second-Line Pharmacologic Management (If Oxytocin Fails Within 30 Minutes)

• Administer sulprostone (where available) or carboprost tromethamine 250 mcg IM, which can be repeated every 15-90 minutes up to a maximum of 8 doses 7, 4
• Carboprost is specifically indicated for PPH due to uterine atony that has not responded to oxytocin and uterine massage 7
• Avoid methylergonovine in hypertensive patients due to risk of severe vasoconstriction and hypertensive crisis 1, 2
• Misoprostol 800-1000 mcg rectally can be used as an alternative uterotonic, though it may cause high fevers (>40°C) with autonomic effects 8

Mechanical Interventions (If Pharmacologic Management Fails)

Intrauterine Balloon Tamponade

• Place intrauterine balloon tamponade as the first surgical intervention if uterotonics fail—this has a 79-90% success rate when properly placed and avoids the need for laparotomy in most cases 1, 5
• Do not delay balloon placement in ongoing massive hemorrhage, as early mechanical intervention prevents progression to coagulopathy 5
• The balloon can remain in place for up to 24 hours 2

Surgical Interventions (Stepwise Escalation)

If balloon tamponade fails, proceed in the following order:

1. Uterine compression sutures (B-Lynch or other brace sutures) as first-line surgical option 6, 5
2. Uterine artery embolization if patient is hemodynamically stable, equipment is available, and expertise exists—highly effective but requires specific resources 5, 4
3. Internal iliac (hypogastric) artery ligation has only 65% success rate and may be ineffective due to collateral circulation, but can be attempted before hysterectomy 5
4. Hysterectomy as definitive last resort when all uterine-sparing measures have failed 5, 4

Etiology-Specific Management (The "4 T's")

Tone (Uterine Atony)—Most Common Cause

• Managed primarily with uterotonics and uterine massage as described above 9, 4
• Active management of third stage with oxytocin is critical, especially in anticoagulated patients, because myometrial contraction (not coagulation) is the primary mechanism for placental bed hemostasis 1

Trauma (Lacerations, Uterine Rupture)

• Requires immediate surgical repair of genital tract lacerations, episiotomy sites, or uterine rupture 9, 4
• Minimize trauma during delivery in anticoagulated patients, as impaired hemostasis exacerbates traumatic bleeding 6

Tissue (Retained Placenta/Products)

• Diagnose with ultrasound examination 2
• Perform manual removal only in cases of severe uncontrollable PPH—routine manual removal increases infection risk and should be avoided 1, 2
• Surgical evacuation if retained products confirmed 2

Thrombin (Coagulopathy)

• Managed with blood product replacement as outlined above, targeting fibrinogen ≥2 g/L 6, 2
• Consider recombinant factor VIIa only for refractory post-hysterectomy bleeding after all standard therapies have failed—carries 3% thrombosis risk 6

Monitoring Requirements

• Continue hemodynamic monitoring for at least 24 hours post-delivery—this period has significant fluid shifts that may precipitate heart failure in women with structural heart disease 1, 2
• Monitor for delayed complications including renal failure, hepatic dysfunction, infection, and Sheehan syndrome (pituitary necrosis) 2
• Serial assessment of hemoglobin, platelet count, fibrinogen, PT/aPTT, and blood gas with lactate 9, 4

Special Population: Anticoagulated Patients

• Women on therapeutic anticoagulation for mechanical heart valves should transition from warfarin to LMWH/UFH at 36 weeks gestation 2
• Discontinue UFH 4-6 hours before planned delivery or epidural placement 6
• Active management of third stage with oxytocin is even more critical in these patients to compensate for impaired hemostasis 1
• Minimize birth trauma through careful technique and consider scheduled delivery to optimize timing relative to anticoagulation 6

Critical Pitfalls to Avoid

• Delaying TXA beyond 3 hours or giving it incrementally—every 15 minutes of delay costs 10% effectiveness 1, 2
• Waiting for laboratory results before transfusing in active severe hemorrhage 2, 5
• Allowing hypothermia or acidosis to develop, which severely impairs coagulation 5, 4
• Using methylergonovine in any patient with hypertension or preeclampsia 1, 2
• Performing routine manual placental removal in non-severe cases 1, 2
• Delaying balloon tamponade placement while attempting additional uterotonics—early mechanical intervention prevents coagulopathy 5
• Underestimating blood loss—visual estimation is notoriously inaccurate, and quantitative assessment with collection drapes is preferred 4, 10