What is the appropriate management of postpartum hemorrhage?

Management of Postpartum Hemorrhage

Immediate First-Line Actions

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

Critical Timing for Tranexamic Acid

• Tranexamic acid must be given within 3 hours of birth—effectiveness decreases by approximately 10% for every 15-minute delay, and administration beyond 3 hours may be harmful. 1
• A second dose of TXA 1 g IV can be given if bleeding continues after 30 minutes or restarts within 24 hours. 1
• TXA should be administered in all cases of PPH regardless of etiology (uterine atony, trauma, retained tissue). 1

Oxytocin Administration

• Oxytocin 5-10 IU should be given slow IV or IM immediately, with the IV route being more effective than IM. 1, 2
• For ongoing bleeding, 10-40 units of oxytocin may be added to 1,000 mL of non-hydrating diluent and run at a rate necessary to control uterine atony. 2

Diagnostic Assessment

Identify the Cause Using the "4 T's" Framework

Tone (Uterine Atony) - Most common cause (>75% of cases):

• Assess uterine firmness by palpation; a soft, boggy uterus indicates atony. 3, 4
• If the uterus is firm, atony is effectively ruled out and other causes must be sought. 4

Trauma (Lacerations, Rupture):

• When bleeding occurs with a firm, well-contracted uterus, genital tract trauma is the leading cause. 4
• Perform systematic visual inspection under adequate lighting of the cervix, vaginal walls, perineum, and periurethral area. 4
• Consider examination under anesthesia if the patient cannot tolerate adequate inspection. 4

Tissue (Retained Products):

• Verify complete placental delivery; retained placenta is defined as spontaneous placental delivery occurring more than 30 minutes after fetal expulsion. 4
• Use transvaginal ultrasound with color Doppler if retained products are suspected; a vascular echogenic endometrial mass with intralesional flow is the most specific sign. 3

Thrombin (Coagulopathy):

• Obtain complete blood count, coagulation panel (PT/PTT, fibrinogen), blood group and screen, and venous blood gas immediately. 1
• Use point-of-care viscoelastic hemostatic assays (VHA) for rapid assessment; fibrinogen is the single most important parameter to monitor. 1

Escalating Pharmacological Management

Second-Line Uterotonics (if oxytocin fails within 30 minutes)

Carboprost (Hemabate):

• Carboprost tromethamine is indicated for postpartum hemorrhage due to uterine atony which has not responded to conventional methods including oxytocin and uterine massage. 5
• Contraindicated in asthma patients due to bronchoconstriction risk. 1, 3

Methylergonovine:

• Methylergonovine 0.2 mg IM is contraindicated in hypertensive patients (>10% risk of vasoconstriction and severe hypertension). 1
• Also avoid in women with asthma due to bronchospasm risk. 1

Blood Product Resuscitation Strategy

Massive Transfusion Protocol (blood loss >1,500 mL)

Initial Transfusion Approach:

• Withhold fresh frozen plasma (FFP) until at least 4 units of packed red blood cells have been given if bleeding persists and coagulation results are not yet available. 1
• After 4 units of packed red blood cells, administer 4 units of FFP and maintain a 1:1:1 RBC:FFP:platelets ratio. 1, 6
• Do not delay transfusion waiting for laboratory results in severe bleeding. 1

Hemostatic Targets:

• Target hemoglobin >8 g/dL and fibrinogen ≥2 g/L during active hemorrhage. 1, 6
• Give cryoprecipitate or fibrinogen concentrate when fibrinogen levels fall below 2 g/L in the setting of ongoing bleeding. 1
• Platelet transfusion is seldom needed unless estimated blood loss exceeds 5,000 mL or platelet count falls below 75 × 10⁹/L. 1

Mechanical and Surgical Interventions

Intrauterine Balloon Tamponade

• Intrauterine balloon tamponade should be implemented before proceeding to surgery or interventional radiology. 1, 6
• For vaginal delivery, perform thorough pelvic examination before balloon insertion to exclude cervical or vaginal lacerations. 1
• For cesarean delivery, introduce the deflated balloon directly into the uterine cavity through the hysterotomy before closure. 1

Surgical Options (if balloon tamponade fails)

• Bilateral uterine artery ligation is recommended as the next surgical step if hemorrhage persists despite correct balloon placement. 1
• Uterine compression sutures (B-Lynch or similar brace sutures) are effective for refractory uterine atony. 1
• Pelvic pressure packing provides rapid stabilization of uncontrolled hemorrhage and can remain for 24 hours. 1

Interventional Radiology

• Arterial embolization is particularly useful when no single bleeding source is identified, but requires hemodynamic stability for transfer. 1, 6
• Multiphasic CT angiography achieves approximately 97% accuracy for identifying active contrast extravasation. 3

Essential Supportive Measures

Temperature Management:

• Maintain normothermia by warming all infusion solutions and blood products and using active skin warming; clotting factors function poorly at lower temperatures. 1, 6

Oxygenation:

• Administer oxygen to achieve arterial oxygen saturation ≥95% in severe PPH. 1

Antibiotic Prophylaxis:

• Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL. 1
• Manual uterine examination requires antibiotic prophylaxis. 6

Monitoring:

• Continue hemodynamic monitoring for at least 24 hours post-delivery due to significant fluid shifts. 1
• Stop transfusing blood components once bleeding has ceased, even if laboratory values remain abnormal. 1

Special Populations

Anticoagulated Patients

• Women receiving therapeutic-dose LMWH have 1.9-fold increased PPH risk (29.6% vs 17.6% in controls). 4
• Active management of third stage with oxytocin is critical in anticoagulated patients, as primary hemostasis depends on myometrial contraction, not coagulation. 1
• If emergent delivery is required on therapeutic anticoagulation, consider protamine (partially reverses LMWH). 1

Secondary (Late) Postpartum Hemorrhage (24 hours to 6 weeks)

Most Common Causes by Delivery Type

After Vaginal Delivery:

• Retained products of conception (RPOC) are found in approximately 32.8% of secondary PPH cases. 3

After Cesarean Delivery:

• Endometritis is the leading cause (RPOC in only 10.8% of cases). 3
• Bladder-flap hematomas >5 cm should raise suspicion for uterine scar dehiscence. 3

Diagnostic Imaging

• Transvaginal ultrasound with color Doppler is the preferred initial study; endometrial thickness >8-13 mm suggests RPOC. 3
• Contrast-enhanced CT can localize bleeding sources and detect vascular complications such as uterine-artery pseudoaneurysm in hemodynamically stable patients. 3

Management

• For confirmed RPOC, surgical curettage is the definitive therapy. 3
• Endometritis requires antibiotic therapy, though antibiotics alone do not control hemorrhage. 3
• Vascular uterine lesions such as pseudoaneurysms are best treated with selective arterial embolization. 3

Critical Pitfalls to Avoid

• Never delay tranexamic acid beyond 3 hours of birth—it becomes ineffective and potentially harmful. 1
• Do not wait for laboratory confirmation of coagulopathy before initiating massive transfusion protocol when blood loss exceeds 1,500 mL. 3
• Avoid prostaglandin F2α and methylergonovine in asthmatic patients due to bronchoconstriction risk. 1, 3
• Never give methylergonovine to hypertensive patients due to severe vasoconstriction risk. 1
• Do not assume uterine atony when the uterus is firm; systematically inspect for genital tract lacerations. 4
• Maintain a low threshold for returning to the operating room if ongoing bleeding is suspected, even after initial hemostatic measures. 1