PPH guidline

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Postpartum Hemorrhage (PPH) - Clinical Guidelines

Definition

Traditional: Blood loss >500 mL after vaginal delivery, or >1000 mL after cesarean delivery
Broader clinical definition (now preferred): Any bleeding causing signs/symptoms of hemodynamic instability, or bleeding that would cause instability if untreated
Primary (early) PPH: Blood loss within the first 24 hours of delivery
Secondary (late) PPH: Blood loss from 24 hours up to 6 weeks postpartum

Note: Due to pregnancy-related plasma volume expansion (~40%), patients may not show signs of shock until >1500 mL has been lost. Blood pressure may not drop until >30% of total blood volume is gone.

Causes - The "4 Ts"

T	Cause	Frequency
Tone	Uterine atony	75-90% of cases
Trauma	Cervical, vaginal, perineal lacerations; uterine rupture; uterine inversion	~20%
Tissue	Retained placental fragments, placenta accreta	~10%
Thrombin	Coagulopathy (hereditary or acquired)	Uncommon

Causes of Secondary PPH

Uterine subinvolution at the placental site, retained placental tissue, genital tract wounds, uterogenital infection

Risk Factors

For uterine atony: Uterine overdistention (polyhydramnios, multiple gestation, macrosomia), prolonged or rapid labor, chorioamnionitis, high parity, oxytocin use during labor, volatile anesthetics, magnesium sulfate, tocolytics
For cesarean hemorrhage: Preeclampsia, active labor disorders, prior hemorrhage, obesity, general anesthesia, intraamniotic infection
For uterine rupture: Prior uterine surgery (most significant), obstructed labor, multiple gestation, abnormal fetal lie, high parity

Prevention - Active Management of the Third Stage of Labor

Early oxytocin administration after delivery
Early cord clamping and cutting
Controlled cord traction
These measures reduce PPH incidence by approximately two-thirds

Initial Assessment & Stabilization

Monitoring: Frequent vital signs - heart rate is the most reliable early sign
IV access: Establish adequate intravenous lines promptly
Labs: CBC with platelets, blood type and crossmatch, fibrinogen, fibrin split products, PT/PTT
Fluid resuscitation: Start lactated Ringer solution
Oxygen: Supplemental O2 to enhance cellular oxygen delivery
Blood: Type and crossmatch; O-negative unmatched blood in true emergencies
Imaging: Real-time ultrasound to identify retained placenta or blood clots

Step-by-Step Management

Step 1 - Physical Measures (Uterine Atony)

Bimanual uterine massage: One fist in the anterior fornix compresses the fundus against the other hand suprapubically
Non-pneumatic anti-shock garments: Can be used in combination with fluid resuscitation in remote settings

Step 2 - Uterotonic Agents (First-Line)

Drug	Dose & Route	Notes
Oxytocin (first-line)	10 units IM after placenta delivery; IV: 5-10 units bolus then 10 units/hr infusion (max 40 units total); or 20-30 units in 1000 mL IV fluid at ≤100 mU/min	Avoid large IV bolus (>10 units) - causes hypotension, nausea, headache. Antidiuretic effect - risk of fluid overload
Methylergonovine maleate (second-line)	0.2 mg IM every 2-4 hours	Contraindicated in hypertension - causes vasoconstriction, severe HTN, coronary artery spasm. Do NOT give IV. Nausea, headache, dizziness
Carboprost (15-methyl PGF2α) (second-line)	0.25 mg IM every 15-90 min, up to 8 doses	Use with caution in asthma - causes bronchospasm, pulmonary HTN, desaturation. Monitor pulse oximetry
Misoprostol (PGE1)	600-1000 mcg oral/sublingual/rectal/vaginal	Use when oxytocin unavailable or when patient is desensitized to oxytocin; 800 mcg intravaginally or 1000 mcg rectally reported

Step 3 - Tranexamic Acid

An antifibrinolytic (lysine analogue) that inhibits plasmin-mediated fibrin degradation
Indicated: When initial medical therapy for PPH fails (ACOG recommendation)
Key evidence: The WOMAN trial (20,060 women) showed TXA given within 3 hours of PPH diagnosis reduced death due to bleeding (RR 0.69; 95% CI 0.52-0.91; P=0.008) with no increase in thromboembolic events
Administer after cord clamping (crosses placenta and enters breastmilk)
Prophylactic TXA: Current evidence does NOT support routine prophylactic use - a multicenter RCT (n=4079) found no reduction in PPH risk vs. placebo when given with oxytocin after vaginal delivery

Step 4 - Tamponade Measures (Before Surgery)

Bakri balloon or large Foley catheter for bleeding at low placental implantation site
Uterine packing with sterile gauze (retrospective evidence supports use)
Jada System (intrauterine vacuum device): Achieved definitive hemorrhage control in >90% of patients at median 3 minutes
Selective pelvic vessel embolization (interventional radiology): Highly effective if patient is stable and facilities available

Step 5 - Surgical Intervention

If medical and tamponade measures fail, proceed to laparotomy. Surgical options include:

B-Lynch compression sutures (brace sutures)
Uterine vessel ligation (uterine artery, ovarian artery)
Internal iliac (hypogastric) artery ligation
Arterial embolization via interventional radiology
Peripartum hysterectomy - definitive treatment when all else fails

All invasive options have roughly equivalent success rates of ~85-90% (per systematic review). If these fail, hysterectomy should not be delayed.

Common indications for emergency hysterectomy: Uterine atony unresponsive to treatment, placenta accreta, uterine rupture, extension of uterine incision.

Management by Cause

Lacerations

Rule out with thorough inspection under adequate lighting if uterus is firm but bleeding continues
Repair with absorbable suture; large hematomas (>4 cm or expanding) require incision, irrigation, packing, and vessel ligation

Retained Placenta / Placenta Accreta

Manual exploration and removal; surgical curettage if needed
Placenta accreta may require emergency pelvic embolization, B-Lynch sutures, or peripartum hysterectomy

Uterine Inversion

Immediate manual replacement (Johnson maneuver): grasp uterus in palm, push firmly back into abdominal cavity, hold for several minutes
Rusch balloon catheter can assist correction
Magnesium sulfate (tocolytic) may help repositioning
May require general anesthesia
Resuscitate aggressively - rapid progression to shock

Coagulopathy (DIC)

Replace fibrinogen early - cryoprecipitate or fibrinogen concentrate
Massive transfusion protocol: early blood product administration with FFP:PRBC ratios
Viscoelastic tests (TEG/ROTEM) help guide product-specific therapy
Recombinant Factor VIIa: NOT universally recommended (multiple adverse events reported to FDA)

Massive Hemorrhage Protocol

Multidisciplinary coordination: Obstetrician, anesthesiologist, nurses, neonatologist, interventional radiology, gynecologic surgeon, blood bank
Massive transfusion protocol (MTP): Early activation improves outcomes
Cell salvage: Useful when autologous blood is limited or patient refuses transfusion; use leukocyte reduction filter; give anti-D immunoglobulin to Rh-negative patients
Lab guidance: Guide initially by clinical assessment; add TEG/ROTEM when available; do not delay transfusion waiting for lab values

Key Evidence Summary (Recent)

WOMAN trial - TXA in PPH showed TXA reduces death from bleeding if given within 3 hours (PMID 28456509)
Recent meta-analysis (PMID 37311484): TXA for cesarean - effective in reducing blood loss

Sources

Creasy & Resnik's Maternal-Fetal Medicine: Principles and Practice, p. 948-950
Rosen's Emergency Medicine: Concepts and Clinical Practice, p. 3419-3421
Miller's Anesthesia, 10e, p. 8906-8909
Textbook of Family Medicine, 9e, p. 518-519
Tintinalli's Emergency Medicine: A Comprehensive Study, p. 3420

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