What is postpartum hemorrhage, how is it diagnosed, and what are its management strategies in a postpartum patient?

Postpartum Hemorrhage: Definition, Diagnosis, and Management

What is Postpartum Hemorrhage?

Postpartum hemorrhage is defined as blood loss ≥500 mL after vaginal delivery or ≥1000 mL after cesarean section, or any blood loss sufficient to compromise hemodynamic stability, occurring within 24 hours of delivery (primary PPH) or from 24 hours to 6-12 weeks postpartum (secondary PPH). 1, 2

• PPH is the leading cause of maternal mortality globally, with most deaths occurring within the first 24 hours after birth 1
• Primary PPH affects 1-5% of all deliveries and represents the most life-threatening form 2, 3
• A woman dies from PPH approximately every 5 minutes worldwide 4

How Do You Know It's Postpartum Hemorrhage?

Diagnosis is based on quantified blood loss meeting threshold criteria OR clinical signs of hypovolemia regardless of measured volume. 1, 2

Quantitative Assessment:

• Blood loss ≥500 mL vaginal delivery or ≥1000 mL cesarean section 1, 3
• Severe PPH defined as blood loss ≥1500-2500 mL 5, 6

Clinical Signs of Hypovolemia (may be absent until large blood loss due to pregnancy adaptations):

• Hypotension and tachycardia 4
• Signs of tissue hypoxia and shock 4
• Altered mental status 4

Identify the Cause Using the "Four T's":

• Tone (>75% of cases): Uterine atony—soft, boggy uterus on palpation 2, 3
• Trauma: Lacerations, uterine rupture, hematomas—requires visual inspection 7, 8
• Tissue: Retained placental fragments—diagnosed by ultrasound 7, 8
• Thrombin: Coagulopathy (DIC, amniotic fluid embolism)—fibrinogen <2 g/L occurs in 17% when blood loss exceeds 2000 mL 2, 8

Imaging When Indicated:

• CT with IV contrast localizes bleeding sources in hemodynamically stable patients, particularly for intra-abdominal hemorrhage 7
• Bladder flap hematomas >5 cm raise suspicion for uterine dehiscence 7
• Ultrasound diagnoses retained products of conception 7

Management of Postpartum Hemorrhage

Immediate First-Line Actions (Within Minutes):

Administer tranexamic acid 1 g IV over 10 minutes PLUS oxytocin 5-10 IU (IV or IM), initiate uterine massage and bimanual compression, and begin fluid resuscitation with physiologic electrolyte solutions. 7, 1

• Tranexamic acid MUST be given within 3 hours of birth—effectiveness decreases by 10% for every 15-minute delay, and administration beyond 3 hours may be harmful 7, 1
• TXA should be given in ALL cases of PPH regardless of etiology (atony, trauma, retained tissue) 7, 1
• Oxytocin 5-10 IU slow IV or IM immediately—IV route more effective than IM 1, 9
• Perform manual uterine examination with antibiotic prophylaxis 6
• Careful visual inspection of lower genital tract for lacerations 6

Second Dose of Tranexamic Acid:

• Give second 1 g dose IV if bleeding continues after 30 minutes or restarts within 24 hours 7, 1

Escalation of Uterotonic Therapy:

If oxytocin fails within 30 minutes, administer sulprostone or increase oxytocin infusion. 6

• Oxytocin maintenance infusion: Add 10-40 units to 1000 mL non-hydrating diluent, run at rate necessary to control atony (not to exceed 40 IU cumulative dose) 9, 6
• Higher oxytocin doses (up to 80 IU) reduce PPH by 47% compared to 10 IU 1

Alternative Uterotonics (Use with Caution):

• Methylergonovine 0.2 mg IM is CONTRAINDICATED in hypertensive patients (>10% risk of severe hypertension and vasoconstriction) 7, 1, 10
• Methylergonovine should be AVOIDED in women with asthma due to bronchospasm risk 7, 2
• Prostaglandin F2α should be AVOIDED in women with asthma (causes bronchoconstriction) and when increased pulmonary artery pressure is undesirable 11, 2

Mechanical Interventions (Before Surgery):

Implement intrauterine balloon tamponade if pharmacological treatment fails—90% success rate when properly placed. 7, 6

• Balloon tamponade should be attempted before proceeding to surgery or interventional radiology 7, 6
• Pelvic pressure packing effective for acute uncontrolled hemorrhage, can remain for 24 hours 7
• Non-pneumatic antishock garment for temporary stabilization while arranging definitive care 7, 1

Resuscitation and Blood Product Management:

Initiate massive transfusion protocol if blood loss exceeds 1500 mL—do NOT delay transfusion waiting for laboratory results. 7, 5

• Transfuse packed RBCs, fresh frozen plasma, and platelets in fixed ratios 7, 5
• Target hemoglobin >8 g/dL and fibrinogen ≥2 g/L during active hemorrhage 7, 6
• Crystalloid fluids should be used only until blood loss becomes severe—overuse increases risk of acute coagulopathy and third spacing 5
• Administer RBC, fibrinogen, and FFP without awaiting laboratory results in severe bleeding 6

Surgical and Interventional Options:

If bleeding persists despite pharmacological treatment and balloon tamponade, proceed to arterial embolization (if hemodynamically stable) or surgical intervention. 7, 6

• Uterine compression sutures (B-Lynch or similar brace sutures) 7
• Arterial embolization particularly useful when no single bleeding source identified—requires hemodynamic stability for transfer 7, 6
• Arterial ligation or hysterectomy as last resort 1, 6

Essential Supportive Measures:

• Maintain normothermia: Warm all infusion solutions and blood products; use active skin warming (clotting factors function poorly at lower temperatures) 7, 6
• Administer oxygen in severe PPH 7, 6
• Re-dose prophylactic antibiotics if blood loss exceeds 1500 mL 7
• Continue hemodynamic monitoring for at least 24 hours post-delivery due to significant fluid shifts 7, 1

Special Considerations for Anticoagulated Patients:

• Active management of third stage with oxytocin is CRITICAL—primary hemostasis mechanism is myometrial contraction, not coagulation 1
• Switch from oral anticoagulants to LMWH/UFH from 36 weeks gestation 7
• Discontinue UFH 4-6 hours before planned delivery 7
• If emergent delivery required on therapeutic anticoagulation, consider protamine (partially reverses LMWH) 7
• Minimize trauma and ensure adequate uterine contraction to compensate for impaired hemostasis 11, 1

Critical Pitfalls to Avoid:

• DO NOT wait for laboratory confirmation of DIC before initiating massive transfusion protocol when blood loss exceeds 1500 mL 2
• DO NOT give tranexamic acid beyond 3 hours after birth—it may be harmful 7, 1
• DO NOT use methylergonovine in hypertensive patients or those with asthma 7, 1, 2
• DO NOT use prostaglandin F2α in women with asthma 11, 2
• DO NOT delay surgical intervention if conservative measures fail—early intervention improves outcomes 6

Post-Hemorrhage Monitoring:

• Monitor for complications: renal failure, liver failure, infection, Sheehan syndrome 7
• Early ambulation with elastic support stockings reduces thromboembolism risk 7
• Consider thromboprophylaxis after bleeding controlled, especially with additional VTE risk factors 7
• 3.5-fold increased risk of recurrent PPH in subsequent pregnancies 2