Management of Perigestational Hemorrhage
For perigestational hemorrhage, immediate administration of tranexamic acid 1 g IV over 10 minutes is the critical first-line intervention alongside uterotonic therapy (oxytocin 5-10 IU slow IV/IM), uterine massage, and aggressive fluid resuscitation, with effectiveness declining by 10% for every 15 minutes of delay. 1, 2
Immediate Interventions (First 0-15 Minutes)
Medical Management:
- Administer oxytocin 5-10 IU slow IV or IM immediately as first-line uterotonic 3, 2
- Give tranexamic acid 1 g IV over 10 minutes within 3 hours of bleeding onset (effectiveness decreases ~10% per 15-minute delay) 3, 1, 2
- Initiate bimanual uterine compression and massage to stimulate uterine contraction 2
- Secure large-bore IV access and begin aggressive fluid resuscitation with physiologic electrolyte solutions 2, 4
Assessment:
- Perform manual uterine examination with antibiotic prophylaxis to identify retained products 5
- Carefully inspect lower genital tract for lacerations or trauma 5
- Obtain baseline labs: CBC, coagulation profile, fibrinogen, crossmatch 2
- Monitor vital signs continuously (ECG, non-invasive BP, pulse oximetry) 6
Escalation if Bleeding Persists (15-30 Minutes)
Second-Line Uterotonics:
- If oxytocin fails, administer sulprostone within 30 minutes of hemorrhage diagnosis 5, 6
- Alternative prostaglandins may be used (avoid methylergonovine if hypertensive) 3, 2
- Administer second dose of tranexamic acid 1 g if bleeding continues after 30 minutes or restarts within 24 hours 2
Critical Considerations:
- Maintain temperature >36°C as clotting factors function poorly with hypothermia 7, 2
- Warm all infusion solutions and blood products 5
- Administer supplemental oxygen 5
Mechanical Interventions (30-60 Minutes)
If pharmacological management fails:
- Intrauterine balloon tamponade is the first-line surgical intervention due to high effectiveness (60-80% success rate) and rapid deployment 7, 1, 5
- This should not be delayed in massive hemorrhage to prevent progression to coagulopathy 7
Transfusion Protocol
Initiate massive transfusion protocol if:
- Blood loss exceeds 1500 mL 2
- Clinical signs of hemodynamic instability despite initial resuscitation 5
Transfusion targets:
- Maintain hemoglobin >8 g/dL 5
- Maintain fibrinogen ≥2-3 g/L (hypofibrinogenemia occurs in 17% of cases with >2000 mL blood loss) 1
- Transfuse RBCs, FFP, and platelets in fixed ratios 2, 8
- Platelet transfusion rarely needed unless count **<75 × 10⁹/L** or blood loss >5000 mL 1
- Administer cryoprecipitate or fibrinogen concentrate early if fibrinogen <2 g/L 1
Definitive Interventions (If Bleeding Continues Beyond 60 Minutes)
Interventional Radiology:
- Uterine artery embolization for hemodynamically stable patients who fail medical management and balloon tamponade 1, 2
- Particularly effective when no single bleeding source is identifiable 1, 2
- CT with IV contrast may help localize bleeding source before embolization 1, 2
Surgical Options (in order of preference):
- Uterine compression sutures 2
- Internal iliac artery ligation (65% success rate, limited by collateral circulation) 7, 1
- Hysterectomy as definitive last resort when all other measures fail 7, 1, 2
Critical Pitfalls to Avoid
- Do not delay tranexamic acid administration - benefit decreases 10% per 15 minutes 1, 2
- Do not delay balloon tamponade in massive hemorrhage while attempting additional medical therapies 7
- Do not wait for laboratory results before treating active hemorrhage 2
- Do not use methylergonovine in hypertensive patients (>10% risk of vasoconstriction) 3, 2
- Do not delay invasive treatment beyond 30-60 minutes if medical management fails 9, 6
Post-Hemorrhage Monitoring
- Continue hemodynamic monitoring for at least 24 hours after delivery due to significant fluid shifts 3, 2
- Monitor for complications: renal failure, infection, Sheehan syndrome 2
- Re-dose prophylactic antibiotics if blood loss exceeded 1500 mL 2
- Early ambulation with elastic support stockings to reduce thromboembolism risk 3