What are the treatment options for postpartum hemorrhage (PPH)?

Treatment of Postpartum Hemorrhage

Immediate First-Line Management (Within Minutes)

Administer tranexamic acid 1 g IV over 10 minutes immediately alongside oxytocin 5-10 IU (IV or IM), initiate uterine massage and bimanual compression, and begin fluid resuscitation—this combination forms the cornerstone of PPH management and must be implemented within 3 hours of birth. 1, 2, 3

Critical Timing Considerations

• Tranexamic acid effectiveness decreases by approximately 10% for every 15-minute delay, and administration beyond 3 hours may be harmful rather than beneficial 2, 3
• A second dose of TXA 1 g IV can be given if bleeding continues after 30 minutes or restarts within 24 hours 3
• TXA reduces bleeding-related mortality and should be administered regardless of PPH etiology (atony, trauma, retained tissue) 1, 2

Concurrent Initial Interventions

• Perform manual uterine examination with antibiotic prophylaxis 4
• Conduct careful visual inspection of the lower genital tract for lacerations 5, 4
• Continue uterine massage 4
• Maintain oxytocin infusion not exceeding cumulative dose of 40 IU 6, 4

Second-Line Pharmacologic Management (If Bleeding Persists After 30 Minutes)

If oxytocin fails to control bleeding, administer sulprostone within 30 minutes of PPH diagnosis. 4

Alternative Uterotonic Agents

• Carboprost (Hemabate) 250 mcg IM is indicated for postpartum hemorrhage due to uterine atony unresponsive to conventional methods 7

  • Subsequent doses of 250 mcg can be administered at 1.5-3.5 hour intervals 7
  • Total dose should not exceed 2 mg (8 doses) for postpartum bleeding 7
  • Contraindicated in asthma patients due to bronchoconstriction risk 3, 7

• Methylergonovine 0.2 mg IM is an option but has critical contraindications 3

  • Absolutely contraindicated in hypertensive patients (>10% risk of severe hypertension from vasoconstriction) 3
  • Avoid in women with asthma 3

Mechanical Interventions (Before Surgery or Interventional Radiology)

Implement intrauterine balloon tamponade if pharmacologic measures fail—this should be attempted before proceeding to surgery or interventional radiology. 3, 4

Additional Mechanical Options

• Pelvic pressure packing for acute uncontrolled hemorrhage (can remain for 24 hours) 3
• Non-pneumatic antishock garment for temporary stabilization during transfer 3
• Uterine compression sutures (B-Lynch or similar brace sutures) 3

Resuscitation and Blood Product Management

Transfusion Thresholds and Targets

• Initiate massive transfusion protocol if blood loss exceeds 1,500 mL 3, 8
• Do not delay transfusion waiting for laboratory results in severe bleeding 3
• Transfuse packed RBCs, fresh frozen plasma, and platelets in 1:1:1 to 1:2:4 ratio 1
• Target hemoglobin >8 g/dL during active hemorrhage 3, 4

Coagulation Factor Replacement

• Maintain fibrinogen ≥2 g/L during active hemorrhaging—hypofibrinogenemia is the most predictive biomarker of severe PPH 1, 3, 4
• Fibrinogen levels <200 mg/dL are associated with severe postpartum hemorrhage 1
• Administer cryoprecipitate or fibrinogen concentrate if levels <2-3 g/L with ongoing bleeding 2
• Platelet transfusion rarely needed unless PPH exceeds 5,000 mL or platelet count <75 × 10⁹/L 2

Invasive Interventions (For Refractory Bleeding)

If PPH is not controlled by pharmacologic treatments and intrauterine balloon, proceed to arterial embolization or surgery. 4

Interventional Radiology

• Uterine artery embolization is particularly useful when no single identifiable bleeding source exists and should be considered in hemodynamically stable patients who have failed medical management 2, 3
• CT with IV contrast can localize bleeding sources in hemodynamically stable patients, particularly for intra-abdominal hemorrhage 3
• Hospital-to-hospital transfer for embolization is possible once hemoperitoneum is ruled out and if hemodynamic status allows 4

Surgical Options

• Uterine compression sutures (no specific technique favored over another) 4
• Uterine artery ligation (though efficacy decreased due to collateral circulation) 2
• Hysterectomy reserved as last resort when all other measures have failed 2

Essential Supportive Measures Throughout Management

Temperature and Oxygenation

• Maintain normothermia by warming all infusion solutions and blood products and using active skin warming—clotting factors function poorly at lower temperatures 3, 4
• Administer oxygen in severe PPH 3, 4

Monitoring and Prophylaxis

• Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL 3
• Continue hemodynamic monitoring for at least 24 hours post-delivery due to significant fluid shifts 3
• Consider thromboprophylaxis after bleeding controlled, especially with additional VTE risk factors 3

Etiology-Specific Considerations

The "Four T's" Approach

• Tone (Uterine Atony): Most common cause (70-80% of cases)—presents with soft, boggy uterus 5, 9
• Trauma (Lacerations): Most common cause when uterus is firm—requires systematic visual inspection under adequate lighting of cervix, vaginal walls, perineum, and periurethral area 5, 3
• Tissue (Retained Products): Verify complete placental delivery; consider transvaginal ultrasound with Doppler if no laceration found 5, 3
• Thrombin (Coagulopathy): Assess with PT/PTT, fibrinogen, platelet count 5, 8

Common Pitfalls to Avoid

• Do not assume anticoagulation timing matters for vaginal delivery—evidence shows no difference in PPH risk whether LMWH was given <24 hours or >24 hours before delivery 5
• Do not perform manual removal of placenta outside specialized structures except in severe, uncontrollable PPH 1
• Avoid prostaglandin F2α in women with asthma 3