What is the management of postpartum hemorrhage (PPH) in a recently postpartum female?

Management of Postpartum Hemorrhage

Immediate First-Line Pharmacologic Management

Administer tranexamic acid 1 g IV over 10 minutes immediately upon diagnosis of PPH (within 3 hours of birth), alongside oxytocin 5-10 IU IV or IM, initiate uterine massage, and begin fluid resuscitation with physiologic electrolyte solutions. 1, 2

Tranexamic Acid Administration

• TXA must be given within 3 hours of birth—effectiveness decreases by approximately 10% for every 15 minutes of delay, and administration beyond 3 hours may be harmful. 3, 1, 2
• Give a second dose of 1 g if bleeding continues after 30 minutes or restarts within 24 hours of the first dose. 3, 1
• The number needed to treat is 276 to prevent one bleeding-related death. 2
• TXA should be given in all cases of PPH, regardless of whether bleeding is due to genital tract trauma or uterine atony. 1

Oxytocin Administration

• Administer 5-10 IU slow IV or IM immediately, followed by maintenance infusion of 10-40 units in 1,000 mL non-hydrating diluent at a rate necessary to control atony (not to exceed 40 IU cumulative dose). 2, 4
• Higher cumulative doses (up to 80 IU) show a 47% reduction in hemorrhage compared to lower doses (10 IU). 1, 2
• IV route is more effective than IM for PPH prevention. 1

Concurrent Initial Measures

• Perform manual uterine examination with antibiotic prophylaxis. 5
• Conduct careful visual assessment of the lower genital tract for trauma. 5
• Initiate continuous uterine massage. 5
• Begin fluid resuscitation with physiologic electrolyte solutions. 1, 6

Second-Line Pharmacologic Management

If bleeding persists after oxytocin and tranexamic acid:

• Administer sulprostone within 30 minutes of PPH diagnosis if oxytocin fails. 5
• Alternatively, use methylergonovine 0.2 mg IM, but this is absolutely contraindicated in hypertensive patients due to risk of severe vasoconstriction and hypertensive crisis. 1, 2, 7
• Carboprost tromethamine (15-methyl PGF2α) 250 mcg IM can be used for uterine atony unresponsive to oxytocin. 8
• Rectal misoprostol 800-1000 mcg achieves sustained uterine contraction within 3 minutes with 63% hemorrhage control rate within 10 minutes, particularly useful in low-resource settings. 2

Mechanical Interventions

If pharmacologic management fails:

• Implement intrauterine balloon tamponade, which has a success rate of 79.4-88.2% for uterine atony when properly placed. 3, 1, 6, 2
• This should be performed before proceeding to interventional radiology or surgery. 3, 2
• Pelvic pressure packing can be used for acute uncontrolled hemorrhage and can remain for 24 hours. 6

Resuscitation and Blood Product Management

• Initiate massive transfusion protocol if blood loss exceeds 1,500 mL, transfusing packed RBCs, fresh frozen plasma, and platelets in fixed ratio (1:1:1 to 1:2:4). 3, 6
• Target hemoglobin >8 g/dL and fibrinogen ≥2 g/L during active hemorrhage. 6, 5
• Do not delay transfusion waiting for laboratory results in severe bleeding. 6, 5
• Hypofibrinogenemia (fibrinogen <200 mg/dL) is the biomarker most predictive of severe PPH. 3
• Cryoprecipitate or fibrinogen concentrates can be used to increase fibrinogen levels. 3

Definitive Interventions

If bleeding persists despite above measures:

• Uterine artery embolization is particularly useful when no single bleeding source is identified. 2
• Surgical interventions should be used sequentially: uterine compression sutures (B-Lynch), arterial ligation, or hysterectomy as a last resort. 1, 2, 5
• Recombinant activated factor VIIa can be considered for severe refractory bleeding post-hysterectomy, but carries thrombosis risk (3% in case series). 3

Critical Monitoring and Supportive Care

• Continue hemodynamic monitoring for at least 24 hours after delivery due to significant fluid shifts that may precipitate heart failure in women with structural heart disease. 1, 6, 2
• Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL. 2
• Maintain normothermia and normal pH, as clotting factors function poorly at lower temperatures. 6, 5
• Administer oxygen in severe PPH. 5

Common Pitfalls to Avoid

• Never delay TXA administration—every 15-minute delay reduces effectiveness by 10%, and administration beyond 3 hours is potentially harmful. 3, 1, 6, 2
• Do not routinely perform manual removal of placenta except in cases of severe, uncontrollable PPH, as it increases infection and hemorrhage risk. 3, 6, 2
• Avoid methylergonovine in hypertensive patients due to severe vasoconstriction risk. 1, 2
• Do not delay treatment for active hemorrhage while waiting for laboratory results. 6
• Do not use routine episiotomy, as it increases blood loss and anal laceration risk. 9