What is the initial management of postpartum hemorrhage (PPH) in a patient?

Management of Postpartum Hemorrhage

Immediate First-Line Actions (Within Minutes of Diagnosis)

Administer tranexamic acid 1 g IV over 10 minutes immediately upon diagnosis of PPH (blood loss ≥500 mL vaginal delivery or ≥1000 mL cesarean section), alongside oxytocin 5-10 IU (IV or IM), initiate uterine massage and bimanual compression, and begin fluid resuscitation with physiologic electrolyte solutions. 1, 2, 3

Critical Timing for Tranexamic Acid

• TXA must be given within 3 hours of birth—effectiveness decreases by approximately 10% for every 15-minute delay 1, 2, 3
• Administration beyond 3 hours may be harmful and should be avoided 1, 2, 3
• TXA should be given in ALL cases of PPH regardless of etiology (uterine atony, trauma, retained tissue, coagulopathy) 1, 2, 3
• A second dose of TXA 1 g IV can be given if bleeding continues after 30 minutes or restarts within 24 hours 1, 2, 3
• Number needed to treat is 276 to prevent one bleeding-related death 3

Oxytocin Administration

• Administer 5-10 IU slow IV or IM immediately 1, 2, 4
• IV route is more effective than IM for both prevention and treatment 1, 2
• For ongoing bleeding, add 10-40 units to 1,000 mL non-hydrating diluent and run at rate necessary to control atony 4
• Higher cumulative doses (up to 80 IU) show 47% reduction in PPH compared to lower doses (10 IU) 2
• Do not exceed cumulative dose of 40 IU in initial management 5

Physical Examination and Mechanical Interventions

Immediate Manual Assessment

• Perform manual uterine examination with antibiotic prophylaxis 5
• Conduct careful visual assessment of lower genital tract for lacerations 5
• Continue vigorous uterine massage 6, 5
• Perform bimanual compression 1, 3

Intrauterine Balloon Tamponade

• Implement intrauterine balloon tamponade if first-line uterotonics fail within 30 minutes, before proceeding to surgery or interventional radiology 1, 3
• Success rate of 90% when properly placed 3
• Success rates range from 79.4% to 88.2% in uterine atony cases 3

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

Sulprostone or Carboprost

• Administer sulprostone within 30 minutes of PPH diagnosis if oxytocin fails 5
• Carboprost tromethamine 250 mcg IM can be given for refractory postpartum uterine bleeding 7
• Majority of successful cases (73%) respond to single injection of carboprost 7
• Multiple dosing at intervals of 15-90 minutes may be needed; total dose should not exceed 2 mg (8 doses) 7
• Prior treatment with IV oxytocin and uterine massage should be attempted before carboprost 7

Critical Contraindications

• Methylergonovine 0.2 mg IM is absolutely contraindicated in hypertensive patients (>10% risk of severe vasoconstriction and hypertensive crisis) 1, 2, 3
• Methylergonovine should be avoided in women with asthma due to bronchospasm risk 1
• Prostaglandin F2α should be avoided in women with asthma due to bronchoconstriction risk 1

Resuscitation and Blood Product Management

Fluid Resuscitation

• Begin IV fluid resuscitation with physiologic electrolyte solutions immediately 1, 2, 3, 4
• Fluid resuscitation is recommended for PPH persistent after first-line uterotonics or if clinical signs of severity 5

Massive Transfusion Protocol (Blood Loss >1,500 mL)

• Initiate massive transfusion protocol if blood loss exceeds 1,500 mL 6, 1, 3
• Transfuse packed RBCs, fresh frozen plasma, and platelets in fixed 1:1:1 ratio 6, 1, 3
• Do not delay transfusion waiting for laboratory results in severe bleeding—treat based on clinical presentation 6, 1, 3
• Target hemoglobin >8 g/dL during active hemorrhage 1, 3
• Target fibrinogen ≥2 g/L during active hemorrhage 1, 3, 5
• Hypofibrinogenemia <2 g/L (especially <2 g/L) with ongoing bleeding predicts progression to major hemorrhage 6

Coagulation Management

• After 4 units of RBC without coagulation results, give 4 units FFP and maintain 1:1 ratio until results known 6
• Fibrinogen replacement with cryoprecipitate (5-10 mL/kg in children) or fibrinogen concentrate should be considered if fibrinogen <2-3 g/L with ongoing bleeding 6
• Point-of-care testing is preferred over laboratory testing due to speed 6
• Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL 6, 1, 3

Essential Supportive Measures

Temperature and Oxygenation

• Maintain normothermia: warm all infusion solutions and blood products; use active skin warming (clotting factors function poorly below 36°C) 6, 1, 3, 5
• Avoid acidosis as it impairs clotting factor function 6
• Administer oxygen to achieve arterial oxygen saturation ≥95% in severe PPH 1, 2, 3

Advanced Interventions (If Bleeding Persists Despite Above Measures)

Pelvic Pressure Packing

• Highly effective for acute uncontrolled hemorrhage stabilization 6, 1, 3
• Can remain in place for 24 hours with open abdomen and ventilatory support to allow optimization of clotting 6, 1, 3

Surgical Options

• Uterine compression sutures (B-Lynch or similar brace sutures) 1
• Hypogastric artery ligation (may be difficult and time-consuming, efficacy not proven due to collateral circulation) 6
• Hysterectomy for definitive control 5

Interventional Radiology

• Arterial embolization particularly useful when no single bleeding source is identified 6, 1
• Requires hemodynamic stability for safe transfer 6, 1
• Equipment and expertise not available in all centers 6
• Hospital-to-hospital transfer possible once hemoperitoneum ruled out and if hemodynamically stable 5

Imaging Considerations (For Hemodynamically Stable Patients)

• CT with IV contrast is useful in hemodynamically stable patients to localize bleeding sources, particularly for intra-abdominal hemorrhage 6, 1
• Ultrasound can diagnose retained products of conception 6
• Bladder flap hematoma >5 cm should raise suspicion for uterine dehiscence 6
• Imaging has limited role in acute unstable hemorrhage—proceed directly to intervention 6

Post-Hemorrhage Monitoring (First 24-48 Hours)

Intensive Care Requirements

• 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
• Transfer to intensive care unit for extensive surgery, placenta accreta spectrum, or massive transfusion 6
• Monitor for complications: renal failure, liver failure, infection, unrecognized ureteral/bladder/bowel injury, pulmonary edema, disseminated intravascular coagulation, Sheehan syndrome 6, 1, 3

Thromboprophylaxis

• Consider thromboprophylaxis after bleeding controlled, especially with additional VTE risk factors 1, 3
• Early ambulation with elastic support stockings can reduce thromboembolism risk 1, 3

Special Populations: Anticoagulated Patients

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

Common Pitfalls to Avoid

• Do not wait for laboratory results before initiating massive transfusion protocol in severe bleeding 6, 1, 3
• Do not give methylergonovine to hypertensive patients 1, 2, 3
• Do not delay TXA administration—every 15 minutes reduces effectiveness by 10% 1, 2, 3
• Do not perform routine manual removal of placenta except in severe uncontrollable PPH 1, 2
• Do not use protocolled FFP transfusion before 4 units RBC in trauma/atony-related PPH without coagulation results 6