What is the management of a hemorrhage in a pregnant patient?

Management of Hemorrhage in Pregnancy

Immediately administer tranexamic acid 1 g IV over 10 minutes alongside oxytocin 5-10 IU slow IV/IM as first-line therapy, with effectiveness declining 10% for every 15 minutes of delay. 1, 2

Immediate Stabilization (First 5 Minutes)

• Secure two large-bore IV lines (16-18 gauge) and begin aggressive crystalloid resuscitation while simultaneously assessing hemodynamic status through vital signs and quantifying blood loss 3, 4
• Administer oxytocin 5-10 IU slow IV or IM immediately as the first-line uterotonic agent 1, 2
• Give tranexamic acid 1 g IV over 10 minutes within 3 hours of bleeding onset - this is critical as benefit decreases approximately 10% per 15-minute delay 5, 1, 2
• Maintain patient temperature >36°C as clotting factors function poorly with hypothermia 1, 2
• Initiate continuous fetal heart rate monitoring to assess fetal status 3

Critical Diagnostic Steps

Before any digital cervical examination, perform transvaginal ultrasound to exclude placenta previa - digital examination with undiagnosed previa can cause catastrophic hemorrhage 3. The ultrasound should assess:

• Placental location and relationship to cervical os 3
• Signs of placental abruption (retroplacental clot, increased placental thickness) 3
• Retained products of conception if postpartum 2

Obtain immediate laboratory studies: complete blood count, coagulation profile (PT/PTT/INR, fibrinogen), type and crossmatch for 2-4 units packed red blood cells 3, 4

Escalation Protocol Based on Blood Loss

Blood Loss 500-1000 mL (Moderate Hemorrhage)

• Continue uterine massage and bimanual compression as non-pharmacological interventions 2
• Administer second dose of tranexamic acid 1 g if bleeding continues after 30 minutes or restarts within 24 hours 5, 1, 2
• Consider alternative uterotonics if oxytocin fails:
  • Prostaglandin F2α (carboprost) 250 mcg IM every 15-90 minutes (maximum 8 doses) 1
  • Avoid methylergonovine if patient is hypertensive (>10% risk of severe vasoconstriction and hypertensive crisis) 5, 1, 2

Blood Loss >1500 mL (Massive Hemorrhage)

• Activate massive transfusion protocol immediately with 1:1:1 ratio of packed red blood cells, fresh frozen plasma, and platelets 5, 1, 2
• Maintain fibrinogen ≥2-3 g/L - hypofibrinogenemia is the strongest predictor of severe postpartum hemorrhage 5, 1
• Place intrauterine balloon tamponade (60-80% success rate) - this is the first-line surgical intervention and should not be delayed while attempting additional medical therapies 1, 2

Definitive Interventions for Refractory Bleeding

If hemodynamically stable after balloon tamponade:

• Uterine artery embolization by interventional radiology is preferred for patients who fail medical management and balloon tamponade 1, 2

If hemodynamically unstable or embolization unavailable:

• Systematic pelvic devascularization (uterine or internal iliac artery ligation) 2
• Hysterectomy as definitive last resort when all other measures fail 1, 2

Special Considerations for Anticoagulated Patients

For women on therapeutic anticoagulation (e.g., mechanical heart valves):

• Switch from oral anticoagulants to LMWH or unfractionated heparin from 36 weeks gestation 5
• Discontinue UFH 4-6 hours before planned delivery and restart 4-6 hours after delivery if no bleeding complications 5
• If emergent delivery required while on therapeutic anticoagulation, administer protamine (though it only partially reverses LMWH) 5
• Prefer cesarean delivery over vaginal delivery in fully anticoagulated patients to reduce risk of fetal intracranial hemorrhage 5

Critical Pitfalls to Avoid

• Never delay tranexamic acid administration - each 15-minute delay reduces effectiveness by 10% 1, 2
• Never perform digital cervical examination before ultrasound confirmation of placental location - this can cause catastrophic hemorrhage with placenta previa 3
• Do not delay balloon tamponade in massive hemorrhage while attempting additional medical therapies 1
• Do not use methylergonovine in hypertensive patients due to >10% risk of severe vasoconstriction 5, 1, 2
• Do not delay delivery in hemodynamically unstable patients - maternal stabilization often requires delivery 3
• Do not wait for laboratory results before treating active hemorrhage - initiate resuscitation and transfusion based on clinical assessment 2

Post-Hemorrhage Monitoring

• Continue hemodynamic monitoring for at least 24 hours after delivery due to significant fluid shifts that may precipitate complications 5, 1, 2
• Monitor for complications: acute renal failure, adult respiratory distress syndrome, disseminated intravascular coagulation, Sheehan syndrome (pituitary necrosis) 2, 6
• Re-dose prophylactic antibiotics if blood loss exceeded 1500 mL 2
• Serial hemoglobin/hematocrit every 4-6 hours initially 3

Context-Specific Management

For previable/periviable PPROM (<24 weeks): Expectant management carries 60% maternal morbidity risk (including hemorrhage, chorioamnionitis, sepsis) with only 39% neonatal survival - counsel patients that immediate intervention may be safer 5

For placenta accreta spectrum: Consider prophylactic tranexamic acid at delivery, maintain fibrinogen >200 mg/dL (not just >100 mg/dL as in non-pregnant patients), and have interventional radiology available for potential embolization 5