Management of Postpartum Hemorrhage (PPH)

Definition

Due to maternal adaptations in pregnancy, signs of shock may not appear until >1500 mL is lost.

Causes — The "4 Ts"

Step-by-Step Management

Step 1 — Immediate Resuscitation

• 2 large-bore IV lines, aggressive fluid resuscitation with crystalloid
• Blood typing and crossmatch; O-negative blood in true emergencies
• Call for help — multidisciplinary team: obstetrician, anesthesiologist, nursing, blood bank
• Activate Massive Transfusion Protocol (MTP) if hemorrhage is severe
  • FFP : PRBC ratio guidance (traditional 1:1 is being questioned in obstetrics)
  • Prioritize fibrinogen/cryoprecipitate early — fibrinogen depletes rapidly
  • TEG/ROTEM point-of-care testing can guide coagulopathy management

Step 2 — Identify and Treat the Underlying Cause

Uterine Atony (most common)

1. Bimanual uterine massage — one hand transabdominal, fist of the other through the vagina massaging the anterior uterus
2. Uterotonics (see table below)
3. Intrauterine tamponade — balloon (e.g., Bakri/Jada system; >90% success rate) if medications fail
4. Compression sutures — B-Lynch suture if abdomen is already open
5. Uterine/internal iliac artery ligation
6. Interventional radiology — uterine artery embolization (not first-line, not last resort; success rate ~91%)
7. Peripartum hysterectomy — definitive last resort

Genital Tract Trauma

• Inspect carefully: perineum, vagina, cervix
• Surgical repair of lacerations; drain/evacuate hematomas if expanding

Retained Tissue

• Manual removal of placenta or fragments
• Surgical consultation for placenta accreta/increta/percreta (may require hysterectomy)

Coagulopathy

• Treat underlying DIC; replace clotting factors, platelets, fibrinogen

Uterotonic Drug Table

Tranexamic Acid (TXA)

• Mechanism: Lysine analogue → binds plasminogen/plasmin → inhibits fibrin degradation (antifibrinolytic)
• Dose: 1 g IV, given within 3 hours of hemorrhage onset
• The landmark WOMAN trial (20,060 women) showed TXA significantly reduced death from bleeding (RR 0.69; 95% CI 0.52–0.91) when given within 3 hours
• ACOG recommends TXA when initial medical therapy fails
• Give after cord clamping (crosses placenta)
• Prophylactic use after vaginal delivery does not reduce PPH incidence (TRAAP trial)

Surgical & Interventional Options (Escalating)

1. Uterine balloon tamponade (Bakri/Jada) — simple, effective (≤91% success), uterus-preserving
2. B-Lynch compression suture — if abdomen is open
3. Uterine/internal iliac artery ligation
4. Uterine artery embolization (UAE) — preferred over hysterectomy to preserve fertility; bilateral approach usually required due to pelvic collaterals
5. REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) — zone 3 placement; emerging adjunct in extremis
6. Peripartum hysterectomy — definitive; auditing its rate is a quality metric for PPH protocols

Active Management of 3rd Stage (Prevention)

• Oxytocin 10 units IM immediately after delivery of the anterior shoulder (before placental delivery)
• Controlled cord traction
• Uterine massage after placenta delivery
• This reduces PPH incidence significantly

Key Points

• PPH is the leading cause of maternal mortality globally
• Never underestimate blood loss — clinicians consistently underestimate it
• Early, aggressive, multidisciplinary response is key
• Embolization should be neither the first nor last resort — it fits in the middle of the algorithm after medical + tamponade fail