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

Management of Postpartum Hemorrhage

Immediately administer intravenous tranexamic acid 1 g 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, 2

Definition and Recognition

• PPH is defined as blood loss ≥500 mL after vaginal delivery or ≥1000 mL after caesarean section, or any blood loss sufficient to compromise hemodynamic stability 1, 2, 3
• PPH is the leading cause of maternal mortality globally, with most deaths occurring within the first 24 hours after birth 1, 2

Immediate First-Line Management (Within Minutes)

The critical window for TXA is 3 hours—effectiveness decreases by approximately 10% for every 15-minute delay, and administration beyond 3 hours may be harmful. 1, 2, 3

• Administer TXA 1 g IV over 10 minutes as soon as PPH is diagnosed 1, 2
• Give a second dose of 1 g if bleeding continues after 30 minutes or restarts within 24 hours 1, 2
• Simultaneously administer oxytocin 5-10 IU slow IV or IM immediately 2, 3, 4
• Perform uterine massage and bimanual compression (one fist inside vagina against anterior lower uterine segment with counter-pressure on abdomen) 2, 3
• Begin fluid resuscitation with physiologic electrolyte solutions 2, 3
• Monitor vital signs continuously 2, 3

Etiology-Specific Assessment (The "Four T's")

Rapidly identify the cause while initiating treatment:

• Tone (Uterine Atony): Most common cause (>75% of cases), diagnosed clinically by boggy uterus 5, 6
• Trauma: Lacerations, uterine rupture, or incision extensions—requires visual inspection of lower genital tract 5, 3
• Tissue: Retained placenta or products of conception—diagnose with ultrasound showing echogenic endometrial mass with vascularity 1, 3
• Thrombin (Coagulopathy): Inherited or acute coagulopathy from amniotic fluid embolism, abruption, severe pre-eclampsia, or HELLP syndrome 5

Escalation of Pharmacologic Management

If bleeding persists after initial oxytocin:

• Increase oxytocin infusion: combine 10 units in 1,000 mL non-hydrating diluent, run at rate necessary to control atony (up to 40 units total) 4
• Higher oxytocin doses (up to 80 IU) are associated with 47% reduction in PPH compared to lower doses 2
• Administer carboprost tromethamine (prostaglandin) 250 mcg IM if oxytocin fails, after ruling out contraindications 7
• Do NOT use methylergonovine in hypertensive patients due to vasoconstriction risk 1, 3

Mechanical Interventions

If pharmacological management fails:

• Implement intrauterine balloon tamponade with success rates of 79-90% when properly placed 1, 2
• Pelvic pressure packing is effective for acute uncontrolled hemorrhage stabilization and can remain for 24 hours 3
• External aortic compression can be used as temporizing measure 2

Resuscitation and Blood Product Management

• Initiate massive transfusion protocol if blood loss exceeds 1,500 mL 1, 3
• Transfuse packed RBCs, fresh frozen plasma, and platelets in fixed ratio 1, 3
• Target hemoglobin >8 g/dL and fibrinogen ≥2 g/L during active hemorrhage 1, 8
• Do NOT delay transfusion waiting for laboratory results in severe bleeding 1, 3
• Maintain normothermia and normal pH, as clotting factors function poorly at lower temperatures 3, 8
• Administer oxygen to the mother 2

Surgical and Interventional Management

Sequential approach when conservative measures fail:

• Manual uterine examination with antibiotic prophylaxis to identify retained tissue 8
• Surgical repair of lacerations or trauma 1, 3
• Uterine compression sutures (B-Lynch or similar) 2, 3
• Arterial embolization via interventional radiology, particularly when no single bleeding source identified 3, 8
• Uterine or internal iliac artery ligation 2, 3
• Hysterectomy as last resort 2, 8

Imaging Considerations

• CT with IV contrast is useful in hemodynamically stable patients to localize bleeding sources, particularly for intra-abdominal hemorrhage 5, 3
• Ultrasound helps diagnose retained products of conception 3
• CT can identify surgical causes (uterine rupture, genital tract laceration) that will not benefit from empiric embolization 5

Post-Acute 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: renal failure, liver failure, infection, and Sheehan syndrome 1, 3
• Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL 3

Special Populations

• Anticoagulated patients with mechanical heart valves: Switch from oral anticoagulants to LMWH/UFH from 36 weeks gestation and discontinue UFH 4-6 hours before planned delivery 2
• Active management with uterotonics remains critical in anticoagulated patients, as myometrial contraction (not coagulation) is the primary mechanism of placental bed hemostasis 2

Critical Pitfalls to Avoid

• Delaying TXA administration beyond 3 hours or waiting to give it—every 15-minute delay reduces effectiveness by 10% 1, 2, 3
• Delaying treatment for active hemorrhage while waiting for laboratory results 1, 3
• Failing to maintain normothermia and normal pH, which impairs clotting 3, 8
• Using methylergonovine in hypertensive patients 1, 3
• Routine manual removal of placenta in non-severe cases 2
• Underestimating blood loss—visual estimation is notoriously inaccurate 6