How to Manage Postpartum Hemorrhage

Written by Meghan Breed

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Postpartum hemorrhage is defined as ≥1000mL of blood loss irrespective of the delivery route, with associated shock.  Remember the four “T’s”: tone (uterine atony), trauma (lacerations, uterine rupture), tissue (retained placenta, clots) and thrombin (coagulopathies).  Manage the ABCs (especially two large bore IV’s for massive transfusion) and tailor treatment to the specific cause.  Recommendations for balanced transfusion are derived from the trauma literature, but it is important to administer cryoprecipitate earlier to maintain a higher fibrinogen level (at term the normal level is >350mg/dL). See Table 2 for blood product replacement recommendations.

Why does this matter?
Due to increased blood flow to the uterus during pregnancy (~600mL/min as opposed to the normal 60mL/min), postpartum hemorrhage remains the leading cause of maternal illness and death globally.  Rapid intervention by treating the common causes of postpartum hemorrhage and associated hemorrhagic shock can be life-saving.  Anticipating those patients who are at higher risk for postpartum hemorrhage can allow for earlier mobilization of resources and intervention. Risk factors include: prior c-section, multiple gestation, >4 prior vaginal deliveries, large fibroids, baseline low hemoglobin or coagulopathy, abnormal placentation, and more in Table 3. As you can see, this is an important article you will want to read in full text. If not a subscriber, you can read two free articles per month on the NEJM website. This should probably be one of them.

Spill the TTTTea…tone, trauma, tissue and thrombin

  • Tone (the most common cause of postpartum hemorrhage)

    • Risk factors: chorioamnionitis, therapeutic use of magnesium sulfate, prolonged or precipitous delivery, induction of labor or augmentation of labor, uterine fibroids, fetal macrosomia or polyhydramnios, caesarean sections, advanced maternal age and extremes of parity

    • Management of uterine atony:

      • 1st: perform bimanual uterine massage in order to induce uterine contraction by stimulating endogenous prostaglandin release

      • 2nd: treat with medications (You’ll want to check out Table 1 for a review on mechanism of action, route/dose, side effects and contraindications.)

        • 1st line: Oxytocin

        • 2nd line: methylergonovine maleate (Methergine) and carboprost tromethamine (Hemabate)

        • Adjunctive agents: tranexamic acid (TXA) and recombinant factor VIIa

      • 3rd:  mechanical compression via uterine compression sutures (brace sutures) or balloon tamponade systems (Bakri balloon, Figure 2)

      • 4th: If all other methods have failed, surgical methods via bilateral uterine artery ligation, internal iliac artery ligation or hysterectomy can be life-saving.

    • Management of uterine inversion: immediate manual replacement (tocolytic agents may be required to relax the uterus)

  • Trauma

    • Risk factors: operative vaginal delivery, precipitous delivery and episiotomy

    • Management of genital tract lacerations: careful inspection for cervical, vaginal, perineal and rectovaginal lacerations followed by prompt repair with absorbable sutures

  • Tissue

    • Risk factors: incomplete delivery of placenta, placenta accreta spectrum

    • Management of retained placental tissue: evacuation of retained products either manually or with the use of a curette under ultrasound guidance

  • Thrombin

    • Risk factors: pre-eclampsia, HELLP syndrome, intrauterine fetal death, placental abruption, acquired coagulopathy (amniotic fluid embolism) and inherited coagulopathy

    • Management: correct coagulopathy while providing hemodynamic support and delivering the fetus

Postpartum Hemorrhage. N Engl J Med. 2021 Apr 29;384(17):1635-1645. doi: 10.1056/NEJMra1513247.

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