Postpartum Haemorrhage (PPH)

Definition

The 4 T's — Causes

Risk Factors

• Previous caesarean section + placenta praevia (strongest risk for placenta accreta)
• Multiparity, advanced maternal age
• Prolonged or augmented labour
• Macrosomia, polyhydramnios, multiple pregnancy
• Previous PPH, uterine fibroids

Immediate Assessment

• Monitor vital signs frequently
• Establish two large-bore IV cannulae promptly
• Start IV fluid resuscitation (Lactated Ringer's)
• Prepare for blood transfusion
• Real-time ultrasound to identify retained placenta or intrauterine clots
• Review possible causes: atony, lacerations, coagulopathy, adherent placenta, uterine inversion

Management — Stepwise Algorithm

Step 1: Uterotonic Drugs (First Line)

• IV infusion: 20–30 units in 1000 mL at no more than 100 mU/min
• Avoid IV bolus — risk of hypotension and cardiovascular collapse
• Monitor for fluid overload (antidiuretic effect)

• 0.2 mg IM — effective for maintaining uterine tone
• Contraindicated IV (risk of hypertension, CNS vasospasm)
• Avoid in hypertension/pre-eclampsia

• 250 μg IM, repeatable if inadequate response
• Use with great caution (or avoid) in asthma and cardiovascular disease

• 800–1000 μg rectally or transvaginally when conventional pharmacotherapy fails
• Useful in resource-limited settings

Step 2: Non-Surgical Mechanical Measures

• Remove retained placental components
• Intrauterine balloon tamponade (e.g. Bakri balloon, Foley catheter) — success rates reported up to 91%; simple, effective step before surgical intervention
• Uterine packing with sterile gauze (retrospective evidence supports use in atony)

Step 3: Surgical / Interventional Radiology

• B-Lynch compression suture ("brace" suture) — if abdomen is already open; uterus-conserving
• Hayman suture — simpler variant
• Uterine artery ligation (O'Leary technique)
• Internal iliac (hypogastric) artery ligation — controls haemorrhage via transient BP/flow reduction; collateral circulation preserved, subsequent pregnancy possible
• Uterine artery embolisation (UAE) — interventional radiology; primary aim to stop bleeding and preserve uterus; bilateral approach usually required given rich pelvic collateral circulation; not first-line but should not be a last resort
• Hysterectomy — definitive; reserved for refractory cases

Technique note (UAE): Bilateral common femoral artery access → catheterisation of anterior divisions of internal iliac arteries → embolisation (usually uterine artery) with Gelfoam. A negative angiogram does not exclude atony — empirical bilateral embolisation is accepted practice. Recurrent bleeding can usually be managed with repeat embolisation.

Haemostatic Resuscitation

Massive Transfusion Protocol (MTP)

• Early activation with fixed ratios of FFP : PRBCs (guidance from non-obstetric settings is being refined for obstetrics)
• Fibrinogen is key — cryoprecipitate or fibrinogen concentrate should be considered early, as levels drop rapidly
• Viscoelastic point-of-care tests (TEG / ROTEM) guide coagulopathy diagnosis, predict PPH, monitor fibrinolysis, and reduce unnecessary transfusion

Tranexamic Acid (TXA)

• Antifibrinolytic: lysine analogue inhibiting plasminogen/plasmin → prevents fibrin degradation
• The WOMAN trial (20,060 women, RCT): TXA reduced death from bleeding when given within 3 hours of PPH diagnosis (RR 0.69; 95% CI 0.52–0.91; P=0.008), with no increase in thromboembolic events
• ACOG recommends TXA when initial medical therapy fails
• Give after cord clamping (crosses placenta); administer as early as possible within 3-hour window
• Prophylactic use after vaginal delivery has not shown benefit in RCT evidence

Cell Salvage

• Effective in massive obstetric haemorrhage
• Leukocyte-reduction filter removes tissue factor, fetal squamous cells, α-fetoprotein, bacteria
• Cost-effective; especially valuable if blood supply is limited or patient refuses transfusion
• In Rh-negative mothers: anti-D immunoglobulin + Kleihauer–Betke test required

Special Situations

Uterine Inversion

• Rare but dramatic; associated with fundal placentation
• Presents as: beefy-red mass at introitus (complete) or undetectable fundus on abdominal palpation (incomplete)
• Management: tocolysis (magnesium sulfate, β-mimetics, nitroglycerin) to facilitate manual reinversion (Johnson technique — gentle persistent fundal elevation); GA if tocolysis fails
• Resolve inversion before administering uterotonics

Abnormal Placentation (Accreta Spectrum)

• Accreta (84%): adherence to myometrium; Increta (13%): into myometrium; Percreta (3%): through serosa ± adjacent organs
• Incidence ×10 over 50 years; most important risk = prior caesarean + placenta praevia
• Leading cause of peripartum hysterectomy; maternal mortality up to 7%
• Antenatal diagnosis (US ± MRI; sensitivity 33–95%) critical for pre-planned multidisciplinary delivery
• Scheduled caesarean ± hysterectomy at 34–36 weeks; consider pre-operative iliac balloon catheter insertion

Monitoring in Severe PPH

• Central venous pressure (CVP) line or Swan-Ganz catheter for accurate cardiovascular monitoring in extensive haemorrhage
• Prevents errors of over- or under-hydration and pulmonary oedema

Key Metrics / Audit

• Peripartum hysterectomy rate — useful audit measure of PPH algorithm effectiveness in obstetric units

Recent Evidence (2024–2025)

• Uterotonic agents (network meta-analysis, 2025) — updated comparative efficacy of oxytocin, ergometrine, misoprostol, carbetocin and combinations for PPH prevention [PMID: 40237648]
• Blood product transfusion in PPH (systematic review, 2025) — transfusion strategies and blood products for active PPH management [PMID: 39911088]