What are the guidelines for managing postpartum hemorrhage (PPH) in a patient?

Management of Postpartum Hemorrhage

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 aggressive fluid resuscitation—this combination forms the cornerstone of PPH management and must be implemented within 3 hours of birth. 1, 2, 3

Definition and Recognition

• PPH is defined as blood loss ≥500 mL after vaginal delivery or ≥1000 mL after cesarean section, or any blood loss causing hemodynamic compromise 2, 3, 4
• Severe persistent PPH is active bleeding >1000 mL within 24 hours that continues despite first-line measures including uterotonics and uterine massage 5
• PPH is the leading cause of maternal mortality globally, with most deaths occurring within the first 24 hours 2, 3

Immediate First-Line Management (Within Minutes)

Critical Time-Sensitive Interventions

Tranexamic acid administration is time-critical and must occur within 3 hours of birth—effectiveness decreases by approximately 10% for every 15-minute delay, and administration beyond 3 hours may be harmful 1, 2, 3

• Give TXA 1 g IV over 10 minutes as soon as PPH is diagnosed, regardless of etiology (atony, trauma, or retained tissue) 1, 2, 3
• A second 1 g dose should be given if bleeding continues after 30 minutes or restarts within 24 hours 1, 2, 3
• TXA reduces death due to hemorrhage in PPH patients, though the absolute mortality benefit is small (<1%), it is justified given minimal harm, low cost, and the young age of patients 6

Uterotonic Therapy

• Administer oxytocin 5-10 IU slowly IV or IM immediately (this is the most important and effective component of PPH management) 1, 3, 7, 8
• The IV route is more effective than IM for PPH prevention 3
• Do not exceed a cumulative dose of 40 IU oxytocin 4
• If oxytocin fails to control bleeding within 30 minutes, administer sulprostone (where available) 4
• Methylergonovine 0.2 mg IM is contraindicated in hypertensive patients (>10% risk of severe vasoconstriction and hypertension) and should be avoided in asthmatic patients due to bronchospasm risk 1, 3, 9
• Prostaglandin F2α should be avoided in women with asthma due to bronchoconstriction risk 1

Mechanical Interventions

• Perform immediate uterine massage and bimanual compression 1, 2, 3
• Conduct manual uterine examination with antibiotic prophylaxis to identify retained tissue or uterine rupture 4
• Perform careful visual inspection of the lower genital tract to identify lacerations requiring repair 4

Resuscitation Protocol

Fluid Management

• Begin aggressive fluid resuscitation with physiologic electrolyte solutions immediately for persistent PPH or clinical signs of severity 1, 3, 4
• Initiate massive transfusion protocol if blood loss exceeds 1,500 mL 1, 8
• Transfuse packed RBCs, fresh frozen plasma, and platelets in fixed ratio (do not wait for laboratory results during active hemorrhage) 6, 1, 4

Transfusion Targets

• Target hemoglobin >8 g/dL during active hemorrhage 1
• Maintain fibrinogen ≥2 g/L (normal pregnancy levels are 4-6 g/L; levels <2 g/L with ongoing bleeding predict progression to major hemorrhage) 6, 1, 4
• Administer fibrinogen replacement with cryoprecipitate or fibrinogen concentrate if fibrinogen <2 g/L with ongoing bleeding 6

Laboratory Monitoring

• Obtain baseline coagulation studies immediately (platelet count, PT, PTT, fibrinogen) but do not delay treatment waiting for results 6, 5
• Point-of-care testing (thromboelastography/rotational thromboelastometry) is preferred over laboratory testing due to rapid results 6

Second-Line Mechanical Interventions

Intrauterine Balloon Tamponade

• Implement intrauterine balloon tamponade if pharmacological management fails, with success rates of 79-90% when properly placed 1, 2, 3
• This should be performed before proceeding to surgery or interventional radiology 1, 3

Pelvic Pressure Packing

• Pelvic packing is highly effective for acute uncontrolled hemorrhage stabilization and can remain in place for 24 hours (with open abdomen and ventilatory support) 6, 1, 2
• This allows for optimization of clotting and hemostasis 6

Surgical and Interventional Options

Conservative Surgical Measures

• Uterine compression sutures (B-Lynch or similar brace sutures) can control bleeding when other measures fail 1, 5
• Hypogastric artery ligation may decrease blood loss but efficacy is unproven and it can be difficult and time-consuming 6

Interventional Radiology

• Arterial embolization is particularly useful when no single bleeding source is identified at surgery 1, 3, 4
• This requires hemodynamic stability for safe transfer 1
• Hospital-to-hospital transfer for embolization is possible once hemoperitoneum is ruled out and hemodynamics allow 4

Definitive Surgery

• Hysterectomy is the final surgical option for uncontrollable PPH 5

Essential Supportive Measures

Temperature and Metabolic Management

• Maintain normothermia by warming all infusion solutions and blood products and using active skin warming—clotting factors function poorly below 36°C 6, 1, 4
• Avoid acidosis as it impairs coagulation 6
• Administer oxygen in severe PPH 1, 4

Infection Prevention

• Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL 6, 1

Etiology-Specific Considerations (The Four T's)

Tone (Uterine Atony) - Most Common (>75%)

• Treated primarily with uterotonics and uterine massage as described above 1, 8

Trauma (Lacerations, Rupture)

• Requires careful visual inspection and surgical repair 1, 2
• CT with IV contrast is useful in hemodynamically stable patients to localize bleeding sources, particularly for intra-abdominal hemorrhage 1

Tissue (Retained Placenta/Products)

• Ultrasound should be used to diagnose retained products of conception 1, 2
• Manual removal of placenta should NOT be routinely performed except in cases of severe and uncontrollable PPH 6, 3

Thrombin (Coagulopathy)

• Severe early consumptive coagulopathy is associated with abruption, amniotic fluid embolus, and severe bleeding with pre-eclampsia 6
• Early use of FFP before RBC may be required in these cases 6

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, 3
• Monitor for complications: renal failure, liver failure, infection, Sheehan syndrome 1, 2
• Intensive care unit monitoring is often required given the extensive nature of severe PPH 6
• Maintain low threshold for reoperation if ongoing bleeding is suspected 6

Special Populations

Anticoagulated Patients

• Active management of third stage with oxytocin is critical in anticoagulated patients, as the primary hemostasis mechanism is myometrial contraction, not coagulation 1, 3
• Switch from oral anticoagulants to LMWH/UFH from 36 weeks gestation in patients with mechanical heart valves 1, 2
• Discontinue UFH 4-6 hours before planned delivery 1, 2
• Consider protamine if emergent delivery required on therapeutic anticoagulation (partially reverses LMWH) 1
• Cesarean delivery is preferred to reduce fetal intracranial hemorrhage risk 1

Critical Pitfalls to Avoid

• Never delay TXA administration beyond 3 hours—every 15-minute delay reduces effectiveness by 10% 1, 2, 3
• Never delay transfusion waiting for laboratory results during active hemorrhage—treat based on clinical presentation 6, 1, 4
• Never allow patient to become hypothermic or acidotic—this severely impairs clotting 6, 1, 2
• Never use methylergonovine in hypertensive patients 1, 3
• Never routinely perform manual placental removal in non-severe cases—this increases bleeding risk 6, 3
• Never delay escalation to invasive treatments if pharmacological and balloon tamponade measures fail within 30 minutes 10, 4