What is the recommended emergency management of postpartum hemorrhage?

Emergency Management of Postpartum Hemorrhage

Administer tranexamic acid 1 g IV over 10 minutes within 3 hours of delivery onset as soon as postpartum hemorrhage is diagnosed, alongside immediate oxytocin administration and aggressive resuscitation, as this combination reduces bleeding-related mortality. 1, 2

Immediate Resuscitation and Team Activation

• Activate a massive hemorrhage protocol with a designated team leader to coordinate all interventions 2
• Establish large-bore IV access immediately (two 14-16 gauge peripheral lines or ≥8-Fr central line); use intraosseous access if peripheral attempts fail 1, 2
• Begin aggressive fluid resuscitation with warmed physiologic electrolyte solutions 1, 2, 3
• Provide high-flow oxygen to maintain tissue perfusion 1, 2
• Actively warm the patient and all infused fluids; maintain core temperature >36°C as clotting factors function poorly at lower temperatures 2, 4

First-Line Pharmacologic Management

Oxytocin Administration

• Administer oxytocin 5-10 IU slow IV or IM immediately, followed by maintenance infusion of 10-40 units in 1000 mL physiologic solution at a rate necessary to control uterine atony, not exceeding 40 IU cumulative dose 2, 3, 4
• Oxytocin is the first-line uterotonic agent regardless of delivery route 5, 6, 4

Tranexamic Acid Administration

• Administer tranexamic acid 1 g IV over 10 minutes (at 1 mL/min) within 3 hours of birth; effectiveness declines approximately 10% for every 15 minutes of delay 1, 2, 7
• Give a second 1 g dose if bleeding continues after 30 minutes or restarts within 24 hours 1, 7
• Do not administer tranexamic acid if the patient has a known thromboembolic event during pregnancy 7
• The WOMAN trial demonstrated reduced bleeding-related mortality (1.5% vs 1.9%, RR 0.81) when given within 3 hours, with number needed to treat of 276 1

Physical Interventions

• Perform immediate bimanual uterine compression: place a fist inside the vagina against the anterior lower uterine segment with counter-pressure from the other hand on the abdomen 2, 6
• Conduct uterine massage externally 6, 4
• Perform manual uterine examination with antibiotic prophylaxis to identify retained tissue, uterine rupture, or inversion 4
• Carefully inspect the lower genital tract for lacerations requiring repair 6, 4

Laboratory Assessment and Monitoring

• Obtain baseline labs urgently: complete blood count, PT, aPTT, Clauss fibrinogen (not derived fibrinogen), and cross-match for at least 4-6 units of packed red cells 2
• Use point-of-care viscoelastic testing (TEG/ROTEM) when available to guide coagulation management 2
• Place a calibrated collection bag to obtain accurate cumulative blood-loss measurement 2
• Monitor vital signs continuously (heart rate, blood pressure, capillary refill, level of consciousness) and assess for signs of internal bleeding 2

Blood Product Transfusion Strategy

Transfusion Thresholds

• Maintain hemoglobin >8 g/dL during active hemorrhage 4
• Initiate massive transfusion protocol if blood loss exceeds 1500 mL 2, 6, 8

Transfusion Ratios

• Transfuse packed red blood cells, fresh frozen plasma, and platelets in a 4:4:1 or 1:1:1 ratio according to institutional protocol 2
• Do not give fresh frozen plasma routinely; withhold until ≥4 units of RBCs have been transfused unless early coagulopathy is documented 2

Fibrinogen Management

• Hypofibrinogenemia (Clauss fibrinogen <2 g/L) occurs in ~17% of PPH cases with blood loss >2500 mL and is the most common factor deficiency 2
• Maintain fibrinogen level ≥2 g/L during active hemorrhaging 2, 4
• Give cryoprecipitate or fibrinogen concentrate early when fibrinogen is <2-3 g/L with ongoing bleeding 2
• In early severe hypofibrinogenemia (placental abruption, amniotic fluid embolus, sepsis with pre-eclampsia), fibrinogen may be administered before red cells 2
• Platelet transfusion is rarely required unless blood loss >5000 mL or platelet count <75 × 10⁹/L 2

Second-Line Pharmacologic Management

• If oxytocin fails to control bleeding within 30 minutes, administer sulprostone 4
• Sulprostone requires continuous monitoring (ECG, non-invasive blood pressure, pulse oximetry) 9
• Methylergonovine is contraindicated in patients with hypertension due to vasoconstriction risk 2

Mechanical Interventions

• Implement intrauterine balloon tamponade if pharmacological management fails and before recourse to surgery or interventional radiology 2, 5, 4
• Non-pneumatic antishock garment can be used for temporary stabilization while arranging definitive care 2

Surgical and Interventional Radiology Options

• Consider interventional radiology for arterial embolization when no single bleeding source can be identified, particularly in hemodynamically stable patients 2, 4
• Surgical interventions include uterine compression sutures, uterine or internal iliac artery ligation, and hysterectomy if bleeding continues despite medical management 2, 5, 6
• Pelvic pressure packing can be effective for patient stabilization during acute uncontrolled hemorrhage and may be left in for 24 hours 2

Critical Pitfalls to Avoid

• Do not delay treatment for active hemorrhage while waiting for laboratory results 2
• Do not delay tranexamic acid administration; every 15-minute delay reduces effectiveness by 10%, with no benefit after 3 hours 1, 2, 7
• Do not rely on derived fibrinogen values; only Clauss fibrinogen provides accurate measurement 2
• Do not perform manual removal of placenta outside specialized structures except in severe uncontrolled hemorrhage 1
• Do not use crystalloid fluids excessively once blood loss becomes severe, as this increases risk for acute coagulopathy and third spacing 8

Post-Acute Management

• Monitor for complications including renal failure, liver failure, infection, and Sheehan syndrome 2
• Re-dose prophylactic antibiotics if blood loss exceeds 1500 mL 2
• Continue hemodynamic monitoring for at least 24 hours after delivery 2
• Transfer to intensive care unit or specialized recovery unit if invasive treatments were necessary 9