Postpartum Hemorrhage (PPH) - Management

Definition

• Primary PPH: Blood loss ≥500 mL within the first 24 hours of vaginal delivery (≥1000 mL after cesarean). The patient may not show shock signs until >1500 mL is lost due to pregnancy-related hypervolemia.
• Secondary PPH: Hemorrhage from 24 hours up to 6 weeks postdelivery - usually linked to retained placental tissue and/or infection.

The "4 Ts" - Causes

Step-by-Step Management Algorithm

Step 1: Immediate Resuscitation

• Call for help - activate a multidisciplinary team (obstetrician, anesthesiologist, midwife, hematology, interventional radiology, blood bank)
• Establish 2 large-bore IV lines
• IV crystalloid resuscitation; activate massive transfusion protocol (MTP) if needed
• Blood: type and cross-match; use O-negative unmatched blood in emergencies
• Oxygen, monitoring (BP, HR, urine output, pulse oximetry)

Step 2: Identify and Treat the Cause

1. Bimanual uterine massage - one hand transabdominally, fist of other hand through the vagina massaging the anterior uterus. Avoid vigorous downward pressure (risk of inversion or broad ligament injury).
2. Empty the bladder - a full bladder prevents uterine contraction

Uterotonic (Oxytocic) Drugs

Tranexamic Acid (TXA)

• An antifibrinolytic (lysine analogue) that inhibits plasmin-mediated fibrin degradation
• The WOMAN trial (20,060 women, RCT) showed TXA reduced death from bleeding when given within 3 hours of PPH diagnosis (RR 0.69; 95% CI 0.52-0.91)
• ACOG recommends TXA when initial medical therapy fails
• Dose: 1 g IV over 10 min; a second dose of 1 g may be given if bleeding continues after 30 min
• Give after cord clamping (crosses placenta); safe in breastfeeding
• Note: Prophylactic TXA is not currently supported - a multicenter RCT (4079 women) found no benefit over oxytocin alone for prevention

Surgical / Invasive Escalation

1. Uterine balloon tamponade (e.g., Bakri balloon, Foley catheter) - reported success rates up to 91%; simple, effective next step
2. Uterine compression sutures (e.g., B-Lynch suture) - if abdomen is already open
3. Uterine/iliac artery ligation - surgical devascularization
4. Interventional radiology - uterine artery embolization (UAE)
   • Uses Gelfoam via bilateral common femoral artery approach
   • Success rate 95-100%
   • Primary aim: stop bleeding AND preserve uterus
   • Bilateral embolization usually required (extensive pelvic collateral circulation)
   • Not first-line but should not be a "last resort"
5. Cell salvage - useful if blood supply limited or patient refuses transfusion
6. Emergency peripartum hysterectomy - definitive treatment when all else fails; the peripartum hysterectomy rate is an audit metric for institutional PPH protocol effectiveness

Blood Product Transfusion

• Activate MTP early; do not wait for lab results in a deteriorating patient
• Cryoprecipitate/fibrinogen concentrate early - fibrinogen drops early in obstetric hemorrhage
• Use TEG/ROTEM for point-of-care coagulopathy guidance
• FFP:PRBC ratios from trauma settings are being re-evaluated for obstetric settings
• Factor VIIa is not universally recommended (multiple adverse events reported to FDA with off-label use)
• Rh-negative patients: give anti-D immunoglobulin if cell salvage or fetal RBC exposure occurs

Special Scenario: Uterine Inversion

• Stop all uterotonics immediately on diagnosis
• Attempt manual repositioning (push fundus upward through introitus) before removing placenta
• If cervical ring forms, relax with terbutaline 0.25 mg IV/SC or magnesium sulfate 4-6 g IV over 15-20 min
• Once repositioned, restart uterotonics

Secondary PPH

• Causes: retained placental tissue, endometritis
• Management: antibiotics, surgical evacuation of retained products, uterotonics

• Rosen's Emergency Medicine, p. 3004-3038
• Roberts and Hedges' Clinical Procedures in Emergency Medicine, p. 3942-3960
• Miller's Anesthesia 10e, p. 2823-2846
• Grainger & Allison's Diagnostic Radiology, p. 261-285
• Creasy & Resnik's Maternal-Fetal Medicine, p. 3226

PPH Drug Dosages - Malaysia MOH Guidelines

Active Management of Third Stage of Labour (Prophylaxis)

• Syntometrine is contraindicated in hypertension, pre-eclampsia, cardiac disease, and sepsis
• Delayed cord clamping: not earlier than 1 min, before 5 min from delivery
• Follow with controlled cord traction (CCT) and uterine massage

Treatment of Active PPH

Step 1 - First-Line Uterotonics

Step 2 - Second-Line Uterotonics (if 1st line fails)

Step 3 - Tranexamic Acid (TXA)

• TXA is mandatory in all active PPH cases per the Malaysia MOH/Patient Blood Management Consensus
• TXA should also be considered prophylactically in high-risk patients (placenta praevia, morbidly adherent placenta, previous PPH, patients refusing blood products)

PPH in Caesarean Section (Malaysia MOH Expert Recommendation)

Blood Products & Coagulation Management

Malaysia MOH PPH Management Flow (by Cause)

Escalation to Surgical/Invasive Options

1. Intrauterine balloon tamponade (Bakri balloon / Foley catheter)
2. B-Lynch compression suture (if abdomen open)
3. Pelvic devascularisation (uterine/internal iliac artery ligation)
4. Uterine artery embolization (angiographic - in haemodynamically stable patients)
5. Peripartum hysterectomy - consider early; definitive treatment

Reference documents:

• Malaysia MOH Perinatal Care Manual 4th Ed. (2020)
• Malaysia MOH Training Manual on Management of PPH (2016) - referenced in the Patient Blood Management Consensus
• PPH Burden, Management and Challenges in Malaysia - Expert Recommendations (2025)