How should postpartum hemorrhage (PPH) be managed in a postpartum woman?

Management of Postpartum Hemorrhage

Immediately administer tranexamic acid 1 g IV over 10 minutes alongside oxytocin 5-10 IU (IV or IM) the moment PPH is diagnosed, but only if within 3 hours of birth—beyond this window, tranexamic acid becomes potentially harmful. 1, 2, 3

Immediate First-Line Actions (Within Minutes)

Critical Time-Sensitive Pharmacotherapy

• Tranexamic acid 1 g IV over 10 minutes must be given within 3 hours of birth, as effectiveness decreases by 10% for every 15 minutes of delay 1, 2, 3
• Administration beyond 3 hours transitions from beneficial to potentially harmful 1, 2, 3
• A second 1 g dose can be given if bleeding continues after 30 minutes or restarts within 24 hours 1, 2
• Number needed to treat is 276 to prevent one bleeding-related death 1, 2

Concurrent Uterotonic Therapy

• Oxytocin 5-10 IU slow IV or IM immediately, followed by maintenance infusion of 10-40 units in 1000 mL non-hydrating diluent 2, 4
• Higher cumulative doses (up to 80 IU) show 47% reduction in hemorrhage compared to lower doses 2
• The infusion rate should be titrated to control uterine atony, not to exceed 40 IU cumulative dose initially 2, 4

Mechanical Maneuvers

• Begin uterine massage and bimanual compression immediately 3
• Initiate fluid resuscitation with physiologic electrolyte solutions 3, 4

Second-Line Pharmacologic Management

When Oxytocin Fails

• Methylergonovine 0.2 mg IM is effective but absolutely contraindicated in hypertensive patients (>10% risk of severe vasoconstriction and hypertensive crisis) 1, 2, 5, 6
• 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 1, 2

Resuscitation and Blood Product Management

Massive Transfusion Protocol Triggers

• Initiate if blood loss exceeds 1,500 mL 1, 3
• Transfuse packed RBCs, fresh frozen plasma, and platelets in fixed ratio (1:1:1 to 1:2:4) 7, 1
• Do not delay transfusion waiting for laboratory results in severe bleeding 3

Target Parameters

• Hemoglobin >8 g/dL during active hemorrhage 1, 3
• Fibrinogen ≥2 g/L (or ≥200 mg/dL) 1, 3
• Hypofibrinogenemia (<200 mg/dL) is the biomarker most predictive of severe PPH 7, 1
• Use cryoprecipitate or fibrinogen concentrates to increase fibrinogen levels 7, 1

Mechanical Interventions

Intrauterine Balloon Tamponade

• Success rate of 79.4-90% for uterine atony when properly placed 1, 2, 3
• Should be implemented before proceeding to interventional radiology or surgery 1, 2

Pelvic Pressure Packing

• Effective for acute uncontrolled hemorrhage stabilization 1, 2, 3
• Can remain in place for 24 hours 1, 3

Definitive Interventions (Sequential Approach)

When Conservative Measures Fail

• Uterine artery embolization is particularly useful when no single bleeding source is identified 1, 2, 3
• Surgical interventions should proceed sequentially: uterine compression sutures (B-Lynch) → arterial ligation → hysterectomy as last resort 1, 2
• Recombinant activated factor VIIa can be considered for severe refractory bleeding post-hysterectomy, but carries 3% thrombosis risk 7, 1

Critical Supportive Measures

Temperature and Oxygenation

• Maintain normothermia: warm all infusion solutions and blood products, use active skin warming—clotting factors function poorly at lower temperatures 7, 3
• Administer supplemental oxygen in severe PPH 3

Monitoring 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
• Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL 1, 3

Common Pitfalls to Avoid

Critical Timing Errors

• Delaying tranexamic acid reduces effectiveness by 10% for every 15 minutes, and administration beyond 3 hours is potentially harmful 1, 2, 3
• Treatment for active hemorrhage should not be delayed while waiting for laboratory results 1

Contraindications to Remember

• Never use methylergonovine in hypertensive patients due to severe vasoconstriction risk 1, 2
• Manual removal of placenta should not be performed routinely except in cases of severe, uncontrollable PPH, as it increases infection and hemorrhage risk 7, 1, 2

Monitoring Gaps

• Failure to continue monitoring for 24 hours post-delivery misses delayed complications from fluid shifts 1, 2, 3
• Not maintaining normothermia impairs coagulation cascade function 7, 3