Treatment algorithm

Your Organizational Guidance

ebpracticenet urges you to prioritize the following organizational guidance:

Multidisciplinaire richtlijn Postpartumzorg in de eerste lijn (deel 1)Published by: Werkgroep Ontwikkeling Richtlijnen Eerste Lijn (Worel)Last published: 2022Guideline multidisciplinaire des soins postnatals dans la première ligne de soins (partie 1)Published by: Groupe de Travail Développement de recommmandations de première ligneLast published: 2022Multidisciplinaire richtlijn Postpartumzorg in de eerste lijn (deel 2)Published by: Werkgroep Ontwikkeling Richtlijnen Eerste Lijn (Worel)Last published: 2024Guideline multidisciplinaire des soins postnatals dans la première ligne de soins (partie 2)Published by: Groupe de Travail Développement de recommmandations de première ligneLast published: 2024

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

primary postpartum hemorrhage: initial presentation

1st line – fluid resuscitation and supportive care

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ACUTE
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primary postpartum hemorrhage: initial presentation
1st line – 

fluid resuscitation and supportive care

First-line treatment of primary PPH involves the administration of intravenous fluids, together with concurrent administration of uterotonics and uterine massage.[2][12]​​[101]​​

  • All of these must ideally be initiated within 15 minutes of a PPH diagnosis.[72]

Ensure immediate resuscitation measures to prevent the development of hemorrhagic shock, metabolic acidosis, and coagulopathy.[2][12]​​[101]​​

  • Assess and treat any signs of shock using ABCDE principles and standard protocols.

Establish intravenous access using two large bore cannulas, typically 16-18 gauge, and promptly collect blood samples for type and crossmatch, complete blood count, and coagulation studies, including fibrinogen levels.[2]

Initiate fluid resuscitation with an isotonic crystalloid, while simultaneously placing a Foley catheter to decompress the bladder and monitor hourly fluid intake and urine output.​[5][49]

  • Balanced crystalloids (e.g., Ringer lactate) are preferred over saline because of the potential risks associated with saline-containing solutions, including hyperchloremic acidosis and compromised kidney function.[103]

Consider the benefits of hypotensive fluid resuscitation alongside early administration of blood products. Follow your local protocol for PPH resuscitation.

  • The traditional approach to fluid resuscitation in cases of significant blood loss due to PPH has centered around aggressive volume replacement. The prevailing notion has been to administer large volumes of crystalloid fluid (4-5 liters for every liter of blood lost), aiming to swiftly restore circulating blood volume and normalize blood pressure.[49][104] However, contemporary data have presented an alternative perspective, introducing the concept of hypotensive fluid resuscitation (or permissive hypotension) during the initial stages of hemorrhagic shock.[105][106]

  • The hypotensive fluid resuscitation approach advocates early and assertive administration of blood products instead of relying heavily on extensive crystalloid replacement. The primary objective is to prioritize the prompt delivery of blood products while mitigating the risks associated with aggressive crystalloid infusion, e.g., dilutional coagulopathy; the disruption of pre-existing blood clots due to heightened intravascular pressures; and the development of hypothermia.[2]

  • By employing small-volume (500 mL) boluses of fluid, the restrictive approach to intravenous fluid resuscitation aims to minimize the incidence of third spacing and fluid extravasation. This strategy, in turn, helps to preserve hemodynamic stability, sustain cardiac function, and maintain renal perfusion by averting the adverse effects of increased intra-abdominal pressure.[107][108]

Ensure serial assessments to determine the effectiveness of resuscitation. These evaluations aim to ensure the restoration of normal mental status, and to achieve and maintain the targeted mean arterial pressure, adequate urine output, and normal serum pH and bicarbonate levels.[110] Monitor:

  • Lactate: serial measurements of serum lactate are a valuable tool for guiding ongoing resuscitation efforts. Persistently elevated lactate levels indicate tissue hypoperfusion and the need for continued resuscitation.[111]

  • Arterial blood gas (ABG) or venous blood gas (VBG): assessments of serum pH and bicarbonate can be useful adjunctive markers to determine successful resuscitation.[110] Significant metabolic acidosis may indicate under-resuscitation in severe PPH.

  • Electrolytes: assessment for electrolyte derangements (including hyperkalemia, hypocalcemia, and hypomagnesemia) is paramount during massive transfusion and large volume resuscitation. It facilitates early correction to avoid cardiac arrhythmias.[112]

Consider a patient warming system (e.g., Bair Hugger) to counteract hypothermia, which may develop in the setting of maternal hypoperfusion.​[4][21]

Additional initial management steps for PPH depend on which of the four Ts (Tone, Trauma, Tissue, Thrombin) has been identified as the cause of PPH and the severity of the hemorrhage.[2]

  • Be aware that there may be more than one of the 4Ts contributing to an individual woman’s PPH. See Diagnosis approach.

Close monitoring of the patient's condition, vital signs, and ongoing assessment are essential throughout the management process.​[6][21]​​[101]

Plus – uterotonic

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ACUTE
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primary postpartum hemorrhage: initial presentation
Plus – 

uterotonic

Treatment recommended for ALL patients in selected patient group

Suspect and treat atony first as the most likely underlying etiology of PPH.[2][12]

  • Uterine atony is the most common cause of PPH, accounting for 70% to 80% of cases, and steps to address it typically form a routine part of the initial management in every patient with PPH.[2][20]​​[21][49]​​

  • Key steps in initial management of atony are administration of uterotonics, uterine massage, and consideration of tranexamic acid.[12][101]​​

Administer a uterotonic as soon as PPH is diagnosed. Additional uterotonics may be used if needed.[2][12]​​[101]​​

  • The most common uterotonics (i.e., oxytocin, methylergonovine, carboprost, misoprostol) all have similar efficacy and the choice between them is often determined by local protocols, together with the availability of intravenous access and any uterotonic that was used as prophylaxis in the third stage of labor.[2][122]

Oxytocin

Administer oxytocin as the first-line therapy for the medical management of PPH.[5]​​[21][49]​​

  • Oxytocin is typically administered concomitantly with uterine massage.

  • It works immediately by stimulating oxytocin receptors in the uterus to induce uterine contractions, as the half-life of oxytocin is 1 to 6 minutes.[21]

  • Intravenous administration is preferred.[5][49]​​ Oxytocin can also be administered intramuscularly if intravenous access is not available.

  • Take care to avoid rapid intravenous bolus administration of high-dose oxytocin, as this may induce hyponatremia, hypotension, tachycardia, and arrhythmias.

  • Oxytocin is rarely contraindicated, but should not be used in patients with significant hypotension or syndrome of inappropriate antidiuretic hormone secretion (SIADH).

A second uterotonic is required in addition to oxytocin in 3% to 25% of cases of PPH.[2]

  • In the case of inadequate response and ongoing bleeding, ensure rapid administration of an additional agent.

Methylergonovine

Methylergonovine (an ergot alkaloid) is the most commonly selected add-on option for the treatment of uterine atony after oxytocin.[21]

  • Methylergonovine stimulates uterine smooth muscle and uterine vascular alpha-1-adrenergic receptors, resulting in sustained vasoconstriction and bleeding resolution.[21]

  • Intramuscular methylergonovine is preferred over the oral formulation in the acute treatment of PPH. Methylergonovine can also be given orally for 2-7 days as an adjunct to intramuscular methylergonovine to prevent recurrent PPH in some patients.

  • Methylergonovine is contraindicated in patients with hypertension and cardiovascular disease, including stroke and Raynaud disease.

Carboprost

Carboprost (a prostaglandin F2-alpha analog) is an alternative add-on option for the treatment of uterine atony.[2][21]

  • Carboprost acts as a prostaglandin F2-alpha agonist in the uterine myometrium, stimulating uterine contractions.

  • It is contraindicated in patients with asthma, and is relatively contraindicated in patients with hypertension or active cardiac, hepatic, or pulmonary disease.

Misoprostol

Misoprostol (a prostaglandin E1 analog) is another add-on option used for the treatment of uterine atony. Misoprostol acts as a prostaglandin E1 agonist in the uterine myometrium.[2][21]

  • It can be administered sublingually, orally, or rectally. Repeat doses are not recommended.

  • There are few if any absolute contraindications.

If uterotonics, in combination with other initial interventions, fail to adequately control bleeding, ensure prompt escalation to other more intensive options such as tamponade or surgical techniques.[2]

Primary options

oxytocin: 10-40 units intravenously as a continuous infusion; 10 units intramuscularly

More

Secondary options

methylergonovine: 0.2 mg intramuscularly every 2-4 hours; 0.2 mg orally three to four times daily for up to 7 days

OR

carboprost tromethamine: 0.25 mg intramuscularly every 15-90 minutes, maximum 2 mg/total dose

OR

misoprostol: 600-1000 micrograms orally/sublingually/rectally as a single dose

Plus – uterine massage

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ACUTE
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primary postpartum hemorrhage: initial presentation
Plus – 

uterine massage

Treatment recommended for ALL patients in selected patient group

Perform a uterine massage as an initial intervention for uterine atony.[2][21][49][101]

  • It is important to concomitantly administer uterotonics, initiate fluid resuscitation, and address any other underlying cause of PPH.

  • Ensure the patient’s bladder is emptied to facilitate uterine contraction, perform a bimanual pelvic exam to assess for retained placental tissue and to remove any remaining clots from within the uterus, and perform uterine massage.[2]

To perform effective uterine massage:[2][21]

  • Place your hand over the uterine fundus.

  • Apply gentle but firm circular or kneading motions directly over the uterine fundus with continuous pressure to stimulate uterine contractions.

  • Start uterine massage at the fundus of the uterus and gradually move downward towards the cervix. This helps expel any clots or retained products and encourages effective contractions through the stimulation of endogenous prostaglandins.

  • The uterus should become more firm and decrease in size as uterine atony improves. Assess ongoing bleeding and monitor vital signs to determine the effectiveness of the massage.

In the scenario of lower uterine segment atony, the fundus is typically firm and well contracted, while the lower uterine segment remains dilated and atonic.[2]

  • Perform a bimanual pelvic exam to remove any remaining clots from the lower uterine segment.

  • Employ bimanual uterine compression with the concomitant administration of uterotonics.

Consider – tranexamic acid

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ACUTE
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primary postpartum hemorrhage: initial presentation
Consider – 

tranexamic acid

Treatment recommended for SOME patients in selected patient group

Guidelines vary on the indications for administering tranexamic acid as part of PPH management. Check your local protocol.

  • Tranexamic acid functions as an antifibrinolytic agent by impeding the activation of plasmin, thereby inhibiting the degradation of fibrinogen and fibrin. The rationale behind administering tranexamic acid is its potential to mitigate bleeding, as increased fibrinolysis is observed during the early stages of hemorrhage.[116][123]

  • The WOMAN trial demonstrated significant reductions in maternal mortality (1.2% vs. 1.7%, P = 0.008) and need for surgical intervention in patients with PPH who received tranexamic acid within 3 hours of birth when compared with placebo.[124]

  • A Cochrane review based on the WOMAN trial and a smaller French trial (20,212 women in total) concluded that intravenous tranexamic acid given within 3 hours of birth reduced the risk of maternal death due to bleeding in women with primary PPH (risk ratio 0.81, 95% CI 0.65 to 1.00). This was without increasing the risk of thromboembolic events and irrespective of vaginal versus cesarean delivery.[125]

The American College of Obstetricians and Gynecologists (ACOG) recommends to consider tranexamic acid if initial medical therapy for PPH fails, and highlights that the benefit seen in the WOMAN trial was primarily in women treated within 3 hours of delivery.[2]

  • The ACOG-endorsed Safe Motherhood Initiative recommends to consider tranexamic acid if estimated blood loss (EBL) >1000 mL despite initial interventions and/or administration of ≥2 uterotonics has failed to control bleeding.[6]

The World Health Organization (WHO) and the International Federation of Gynecology and Obstetrics (FIGO) both recommend the simultaneous administration of tranexamic acid alongside uterotonics as a standard first-line treatment for all women diagnosed with PPH following vaginal or cesarean delivery.[49][102]

  • Tranexamic acid is recommended as part of the standard management protocol by WHO and FIGO regardless of the underlying cause of PPH. It must be administered as soon as PPH is clinically diagnosed and within 3 hours of delivery.

  • Do not give tranexamic acid more than 3 hours after birth as there is no clear evidence of benefit.

While the current obstetric dose of tranexamic acid does not pose a significant risk of thrombosis, caution should still be exercised when administering tranexamic acid to patients at higher risk of thrombotic events.[126] It is important to note that tranexamic acid is contraindicated in patients with renal dysfunction due to its renal clearance.

Primary options

tranexamic acid: 1 g intravenously as a single dose, may repeat dose once

Consider – blood product transfusion

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ACUTE
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primary postpartum hemorrhage: initial presentation
Consider – 

blood product transfusion

Treatment recommended for SOME patients in selected patient group

Effective resuscitation prioritizes early replacement of blood products.[107]

  • Thresholds for administering blood products vary between guidelines and PPH care bundles.[21]

  • If coagulopathy is identified, replacement of clotting factors, fibrinogen, or other factors is indicated.[2]

  • The American College of Obstetricians and Gynecologists (ACOG) recommends initiating immediate preparations for blood transfusion as soon as an estimated blood loss (EBL) ≥1500 mL is reached with ongoing bleeding, or when hemodynamic changes such as tachycardia and hypotension become apparent (regardless of degree of EBL).[2]

  • Because such extensive blood loss includes depletion of coagulation factors, it is common for such patients to develop disseminated intravascular coagulation (DIC), requiring the administration of platelets and coagulation factors in addition to red blood cells (RBCs). Use of multicomponent therapy with fixed ratios is recommended.[2]

Note that in an emergency where immediate transfusion is required and there is not time to wait for a crossmatch and/or for supplies of group-specific blood, use group O, Rh-negative emergency blood.[2][113]

  • Switch to a group-specific blood as soon as feasible.[113]

The components of transfusion are:[21]

  • RBCs: consider administering for hemoglobin (Hb) <7 or <8 g/dL, depending on your institution-specific protocol and your assessment of maternal status and coexisting conditions.[21] A typical dose of 1 unit RBC is expected to increase the maternal Hb level by 1 g/dL. 

  • Fresh frozen plasma (FFP): contains plasma proteins, clotting factors such as antithrombin III, factor V, factor VIII, fibrinogen, and proteins C and S. Consider administering after every 1, 4, or 6 units of RBCs or if prothrombin time is prolonged (international normalized ratio or activated partial thromboplastin time >1.5 times the normal value). A FFP dose of 10-20 mL/kg will increase clotting factors by approximately 10% to 20%.

  • Platelets: consider administering if platelet count is <50,000 per microliter or <75,000 per microliter with active bleeding, or after every 1, 4, or 6 units of RBCs administered. One apheresis unit, or 6 units of pooled platelets, will typically increase the platelet count by 25,000-35,000/microliter.[21][68]

  • Cryoprecipitate: contains fibrinogen, clotting factors such as factor VIII, XIII, and von Willebrand factor. Consider administering at a dose of 1 unit per 5-10 kg if fibrinogen level is <100 or <200 mg/dL depending on your local protocol.[21]

Massive blood transfusion may become necessary if there is rapid bleeding that is refractory to initial measures. See the patient group Refractory to initial interventions.

Plus – repair of obstetric lacerations

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ACUTE
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primary postpartum hemorrhage: initial presentation
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with traumatic cause of bleeding
Plus – 

repair of obstetric lacerations

Treatment recommended for ALL patients in selected patient group

If visible lacerations are identified as a cause of bleeding, ensure they are repaired promptly.[2][21]

  • If bleeding is ongoing and uncontrolled after administration of intravenous fluids, uterotonics, and uterine massage, do not delay the decision to move the patient to the operating room for better visualization or administration of anesthesia as a less easily visible traumatic cause may be present.

  • Obstetric trauma is the second most common cause of PPH, accounting for 20% to 30% of cases.[20]

Plus – manual extraction

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ACUTE
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primary postpartum hemorrhage: initial presentation
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with retained products of conception
Plus – 

manual extraction

Treatment recommended for ALL patients in selected patient group

It is crucial to evaluate for retained products of conception in any woman with PPH, as approximately 2% to 3% of all births can be complicated by retained products.[79]

  • If identified, prompt removal of the retained products is necessary to ensure the effectiveness of uterotonics in treating uterine atony.

In cases where PPH occurs in the context of placental retention, the first step is to attempt prompt manual extraction of the placenta.[2] This can help to control bleeding and prevent further complications.

Administer a single dose of antibiotics (e.g., ampicillin, first-generation cephalosporin) to reduce the risk of infection following manual extraction of the placenta (consult your local protocols for appropriate choice).[5]

If manual extraction fails, proceed to surgical removal via dilation and curettage, which should be performed under ultrasound guidance.[2]

  • This approach offers the dual advantage of facilitating the precise removal of retained products and confirming the complete evacuation of the uterus.[77]

Management of placenta accreta spectrum disorder

Placenta accreta spectrum (PAS) disorders (placenta accreta, increta, and percreta) are associated with high maternal morbidity and mortality. If PAS has not been diagnosed prenatally and is suspected when a vaginal delivery is complicated by PPH and a placenta that fails to detach easily, transfer the patient immediately to the operating room for further evaluation.[2]

  • Do not make any additional attempts at manual removal of the placenta in the delivery room.

  • Should continued PPH occur with the diagnosis of likely PAS in the operating room, hysterectomy should be performed without delay.

  • Blood products and preparation for massive transfusion should be readily available, with a low threshold to transfuse intraoperatively.

Plus – manual repositioning of uterus

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ACUTE
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primary postpartum hemorrhage: initial presentation
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with uterine inversion
Plus – 

manual repositioning of uterus

Treatment recommended for ALL patients in selected patient group

Consider the possibility of uterine inversion in any case of PPH where the fundus cannot be palpated.[77]

  • Once uterine inversion is identified, take immediate measures to reposition the uterus to its normal anatomical position. This involves applying steady, continuous pressure on the inverted uterine fundus transvaginally, using a closed fist.[2]

  • It is crucial to initiate this maneuver promptly, as delayed attempts may be more challenging due to progressive uterine edema. Concurrent administration of nitroglycerin or terbutaline can aid in uterine relaxation during the repositioning process. If the placenta has not yet separated, leave it in place during the procedure to prevent additional hemorrhage.[2][21]

  • Ensure administration of uterotonics after correcting uterine inversion to prevent uterine atony and recurrence of inversion.[77]

primary postpartum hemorrhage: refractory to initial interventions

1st line – continue blood product transfusion and supportive care

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ACUTE
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primary postpartum hemorrhage: refractory to initial interventions
1st line – 

continue blood product transfusion and supportive care

Continue the resuscitation measures started during initial treatment, with ongoing assessment of the patient's vital signs, including blood pressure, heart rate, and oxygen saturation. Continue transfusion of blood products.

Massive blood transfusion (MTP) may become necessary.[21]

  • Massive transfusion is characterized by the transfusion of ≥10 units of red blood cells (RBCs) within 24 hours, transfusion of 4 units of RBCs within 1 hour with ongoing need for more blood, or replacement of a complete blood volume.[2][21]

Ensure prompt activation of the MTP in the presence of clinically significant and rapid bleeding. This is a crucial step to minimize maternal morbidity and mortality.[114][115][116] MTPs should be part of a comprehensive PPH management protocol in settings with adequate blood banking.[2]

  • Specific initiation thresholds for MTP and transfusion-specific treatment goals vary between institutions so check your local protocol.

  • One guideline, from the British Committee for Standards in Haematology, has proposed a treatment goal of maintaining the hemoglobin (Hb) level >8 g/dL, fibrinogen >200 mg/dL, platelet count >50,000 per microliter, and activated partial thromboplastin time and prothrombin time levels at <1.5 times the normal values.[68]

  • The use of MTPs has demonstrated a reduction in hemorrhage-related mortality by effectively addressing coagulopathy.[117][118]

MTPs entail the automatic release of RBCs, fresh frozen plasma (FFP), platelets, and cryoprecipitate in predefined ratios.

  • The standard ratio typically follows a 1:1:1 distribution designed to mimic whole blood, consisting of 1 unit of RBCs, 1 unit of FFP, and 1 unit of pooled platelets (equivalent to 6 packs).[2][21] Cryoprecipitate, which is rich in fibrinogen, assumes a vital role within the MTP, especially for patients with disseminated intravascular coagulation (DIC) or fibrinogen levels <200-300 mg/dL.[2]

  • In the US, activation of the MTP can be initiated by a physician or nurse, with the release of blood products continuously provided by the blood bank until the MTP is deactivated.[104][119][120][121]

Plus – additional doses of uterotonic and tranexamic acid

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ACUTE
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primary postpartum hemorrhage: refractory to initial interventions
Plus – 

additional doses of uterotonic and tranexamic acid

Treatment recommended for ALL patients in selected patient group

Multiple uterotonics may be used concomitantly or in rapid succession in the setting of ongoing PPH. It is common for multiple agents to be needed.[5][101][102]

  • Consider prompt escalation to nonmedical interventions such as tamponade or surgical techniques if multiple uterotonics fail to successfully treat PPH secondary to uterine atony.[2]

A second dose of tranexamic acid may be given if persistent bleeding continues after 30 minutes or if recurrent bleeding occurs within 24 hours of the first dose.[49][102]

The STASIS algorithm provides a systematic approach for further evaluation and treatment of severe refractory PPH.[77][104] The steps involve:

  • S: Shift the patient to the operating room for improved visualization. Use temporary compressive measures (e.g., bimanual uterine compression) while transferring the patient to the operating room to decrease ongoing blood loss. See Temporary compressive measures treatment option.

  • T: Tissue, trauma, tamponade. Once in the operating room, a thorough pelvic exam should be conducted to rule out retained tissue or trauma (e.g., lacerations) and address these if identified (e.g., via dilation and curettage under ultrasound guidance to remove retained products of conception that could not be extracted manually). Subsequently, balloon tamponade should be employed. See Uterine tamponade and Repair of deep lacerations treatment options.

  • A: Apply compression via surgical compression sutures to achieve hemostasis. See Surgery treatment option.

  • S: Systemic devascularization. Consider techniques such as O'Leary, ovarian, hypogastric, quadruple, or internal iliac sutures. See Surgery treatment option.

  • I: Interventional radiology. Consider uterine artery embolization if the patient's condition is sufficiently stable. See Surgery treatment option.

  • S: Subtotal/total hysterectomy. Finally, if the prior interventions prove ineffective in controlling refractory PPH, the surgical team should proceed with subtotal or total hysterectomy. See Surgery treatment option.

Primary options

oxytocin: 10-40 units intravenously as a continuous infusion; 10 units intramuscularly

More

OR

methylergonovine: 0.2 mg intramuscularly every 2-4 hours; 0.2 mg orally three to four times daily for up to 7 days

OR

carboprost tromethamine: 0.25 mg intramuscularly every 15-90 minutes, maximum 2 mg/total dose

OR

misoprostol: 600-1000 micrograms orally/sublingually/rectally as a single dose

OR

tranexamic acid: 1 g intravenously as a single dose, may repeat dose once

Consider – temporary compressive measures

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ACUTE
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primary postpartum hemorrhage: refractory to initial interventions
Consider – 

temporary compressive measures

Treatment recommended for SOME patients in selected patient group

Temporary compressive measures are recommended to mitigate blood loss in cases of severe PPH refractory to medical management.[101]

  • These measures aim to reduce uterine blood flow until appropriate care or transfer to a tertiary care facility is feasible.

  • They are particularly useful in low-resource settings.

Bimanual uterine compression and aortic compression are examples of temporizing compressive measures for refractory PPH caused by uterine atony.[2][5]

  • To perform bimanual uterine compression, place one hand in the anterior vaginal fornix and position the other hand behind the uterine fundus, allowing for compression of the uterus between the hands.[21]

  • External aortic compression entails applying external compression, using a closed fist, at the level of the umbilicus, slightly leftward of the midline.

  • These measures can help decrease blood loss from the uterus until the underlying source of bleeding can be identified and appropriately addressed.

Nonpneumatic antishock garments (NASGs) have emerged as a potential solution for managing refractory PPH and stabilizing patients experiencing hypovolemic shock, particularly in resource-limited settings.[5][127]

  • These garments serve as a temporary compression device and offer initial aid by reducing uterine blood loss. Designed with neoprene and Velcro segments, they can be swiftly applied to the ankles, calves, thighs, pelvis, and abdomen, providing circumferential counterpressure to the lower body for a duration of up to 48 hours to decrease pelvic perfusion.

  • This innovative approach aims to buy crucial time and stabilize patients until definitive interventions can be implemented for refractory PPH.

Consider – uterine tamponade

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ACUTE
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primary postpartum hemorrhage: refractory to initial interventions
Consider – 

uterine tamponade

Treatment recommended for SOME patients in selected patient group

Mechanical intrauterine tamponade, where available, is the initial recommended approach for PPH secondary to uterine atony that remains refractory to medical therapy.[2][5]​​[21]​​[77] This approach is most effective when a high-quality device is used promptly after identifying refractory PPH.[49]

Balloon tamponade

Balloon tamponade is recommended as an effective nonsurgical technique in women with PPH due to atony who have not responded to uterotonics, after excluding retained products of conception and uterine rupture as contributory factors.[49]

  • The Bakri balloon is the most commonly used intrauterine balloon tamponade system. It works by applying inward (positive) pressure on the uterine vasculature to decrease uterine blood flow.

  • Evidence for the benefits of intrauterine balloon tamponade is limited.[2] Studies have suggested that mechanical tamponade reduces the need for more invasive procedures and successfully controls PPH in 80% to 100% of cases.[128][129][130][131]

  • The balloon can be inserted manually or with the aid of a speculum and ring forceps, and ultrasound guidance can confirm proper placement at the uterine fundus. It is important to ensure that the entire balloon is within the uterus to provide adequate compression of the lower uterine segment. The Bakri balloon can be inflated with up to 500 mL of saline until bleeding decreases, and is typically left in place for 2 to 24 hours, depending on the amount of drainage.[6][132]

  • Vaginal packing is commonly used alongside the Bakri balloon to secure its position, and a Foley catheter is inserted to drain the bladder and monitor fluid input and output.

  • If a Bakri balloon is not available, alternative devices can be used.[2] These include Foley catheters, condom catheters, or Sengstaken-Blakemore tubes.

Gauze packing

  • In cases where a balloon tamponade device is not available, uterine packing can be performed with gauze.[2]

  • Gauze soaked in saline is layered repeatedly from one uterine cornua to the other with a ring forceps until it extends through the cervical os. As an alternative, multiple Foley catheters can also be filled with 60 mL of saline and inserted inside the uterus for tamponade.[2]

Vacuum-induced hemorrhage control device

Intrauterine vacuum-induced hemorrhage control devices are innovative devices designed to address refractory PPH caused by uterine atony.[133]

  • These devices differ from uterine balloon tamponade in applying a low-level intrauterine vacuum, thereby using negative pressure to constrict myometrial blood vessels and achieve hemostasis.[134] The device consists of a loop with vacuum pores and a vacuum connector that connects to a wall suction.

  • Initial studies on one intrauterine vacuum-induced hemorrhage control device have yielded promising results, indicating its potential efficacy in managing refractory PPH secondary to uterine atony. Notably, the device has demonstrated a high success rate in achieving definitive control of bleeding, often within a short duration of approximately 3 minutes.[133] It is important to note, however, that further research is needed on the applicability of vacuum-induced hemorrhage control devices to a broader population, including those with more severe PPH or those who have undergone cesarean births.[135]

Consider – repair of deep lacerations

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ACUTE
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primary postpartum hemorrhage: refractory to initial interventions
Consider – 

repair of deep lacerations

Treatment recommended for SOME patients in selected patient group

Rapid identification and repair of cervical lacerations, lacerations complicated by arterial bleeding, and high vaginal lacerations is paramount.[2]

  • Uterine artery laceration may require interventional radiology or surgical exploration. Consider transfer to the operating room.

A comprehensive systematic pelvic exam should begin with the identification and repair of deeper lacerations or actively bleeding lacerations to minimize ongoing blood loss.[77]

  • Optimal visualization of the perineum, vaginal vault, vaginal walls, and cervix can be achieved with the use of vaginal wall retractors.

  • To reduce the risk of hematoma formation following the repair of significant or deep sidewall lacerations, absorbent or temporary packing (e.g., gel foam or gauze) may be employed.

The cervix should be routinely examined using ring forceps, as deep cervical lacerations have the potential to cause substantial bleeding.[77]

  • Repairing these lacerations typically involves a running locked technique using synthetic absorbable suture material.

  • Care should be taken to ensure cervical patency at the conclusion of the repair.

In cases where coagulopathy is present or friable vaginal tissue contributes to persistent small areas of bleeding, it may be prudent to consider placing vaginal packing at the end of the repair.[77]

  • This approach allows for the correction of coagulopathy, promotes spontaneous wound closure, and provides hemostasis without the additional trauma that may result from suture placement.

  • Vaginal packing is particularly beneficial for tamponade, preventing the enlargement of vaginal hematomas.

Genital tract hematomas, including labial, vaginal, broad ligament, or retroperitoneal hematomas, can result in significant blood loss, particularly in cases of precipitous delivery or operative vaginal delivery.[2]

  • These hematomas may present with symptoms of rectal or pelvic pressure, pain, or deterioration of vital signs several hours after delivery.[2]

  • In most cases, conservative management is recommended.[2]

  • However, incision and drainage may be indicated in the setting of a rapidly enlarging hematoma or unstable patient. Identifying a single bleeding source within the hematoma can be challenging; thus, exploration with suturing or packing may be necessary to achieve hemostasis. Arterial embolization may be considered as an alternative to incision and drainage.[2]

Have a raised suspicion for an intraperitoneal or retroperitoneal hematoma in the event of significant deterioration of vital signs without an apparent source of external bleeding.[2]

  • In these cases, pursue immediate maternal resuscitation, diagnostic imaging, and surgical intervention or interventional radiology procedures as appropriate.

Consider – surgery

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ACUTE
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primary postpartum hemorrhage: refractory to initial interventions
Consider – 

surgery

Treatment recommended for SOME patients in selected patient group

Surgical management is indicated if PPH fails to respond to repeated doses of uterotonics and tranexamic acid and all other conservative interventions fail to control the bleeding.[5]

  • The specific interventions and their sequence may vary depending on the available resources, healthcare facility capabilities, and the individual patient's condition.[5]

Surgical devascularization and uterine compression sutures

In cases where hemorrhage persists despite medical measures, the surgical team should proceed with a laparotomy to perform surgical devascularization and uterine compression procedures.[2][21][77]

  • Surgical devascularization involves interrupting uterine blood flow and is considered safe with no known adverse effects on future fertility or pregnancy outcomes.[136]

  • While there is no particular order in which particular surgical interventions should occur, surgical devascularization procedures are typically the initial procedures performed. One commonly performed procedure is the O'Leary suture, also known as uterine artery ligation. Bilateral uterine artery ligation involves suture ligation of the uterine vessels at the lateral aspect of the lower uterine segment.[21]

  • If bilateral uterine artery ligation proves ineffective, an alternative option is to perform suture-ligation of the vessels within the utero-ovarian pedicle, known as bilateral utero-ovarian artery ligation.[2][21]

  • Hypogastric artery ligation is considered a last-resort method of surgical devascularization due to its lower success rate of around 50% to 60%, and the extensive surgical dissection required.[2][137]

If surgical devascularization fails to control the bleeding, uterine compression sutures can be attempted as an alternative surgical technique.[2][21][77]

  • The B-lynch suture is the most common compression suture used. It involves placing a series of loops with a large absorbable suture to compress the uterine fundus over the lower uterine segment. During the tying of the suture, manual compression of the uterus by another member of the surgical team is necessary for maximum effect.[138]

  • Other compression sutures such as the Hayman suture, box sutures, Cho multiple square technique, and vertical and horizontal compression sutures can also be considered.[104]

  • Systematic reviews have shown a success rate >90% for managing PPH with compression sutures.[21]

Uterine artery embolization

If a patient with severe refractory PPH is hemodynamically stable and access to interventional radiology services is available, uterine artery embolization (UAE) can be considered as a fertility-sparing alternative to hysterectomy.[2][5][21][49]​​ UAE has high success rates and a lower morbidity profile compared with hysterectomy. However, careful patient selection is essential. The best candidates for UAE are hemodynamically stable, with persistent slow bleeding and have failed less invasive options such as uterotonics, uterine massage, and uterine compression.[2]

  • UAE, when performed promptly, has been shown in some studies to have success rates of up to 95% for refractory PPH.[139][140]

  • UAE is associated with reduced blood loss, shorter operative time, and decreased postoperative length of stay compared with hysterectomy.[139][140]

  • The procedure is associated with a low complication rate.[139][140]

  • There has been conflicting evidence on the safety of UAE in relation to future fertility and pregnancy outcomes with some studies finding no association between UAE and adverse outcomes in subsequent pregnancies, but others reporting higher rates of preterm birth, fetal growth restriction, and placenta accreta spectrum in pregnancies following UAE.[2][140][141]

Note that UAE is not recommended for cases of brisk, ongoing bleeding where there is insufficient time for embolization, or for hemodynamically unstable patients who require immediate surgical intervention.[139]

  • Additionally, if uterine artery ligation has been unsuccessful, UAE may not be possible, and hysterectomy becomes necessary.

Hysterectomy

Hysterectomy is required for definitive surgical management of severe PPH refractory to all other medical and surgical interventions.[2][21]​​

  • No clear recommendations exist to guide the choice between supracervical and total hysterectomy and the decision is generally made by the surgical team on a case-by-case basis, taking account of factors such as the extent and location of bleeding, placental invasion, and the surgical team's expertise.[77]

  • The primary goal is to minimize blood loss and operative time. Careful consideration and surgical skill are necessary to minimize complications and ensure optimal outcomes.

  • Hysterectomy may be appropriate at an earlier stage of management if preservation of future fertility is not desired.[21]

Uterine rupture

In cases of intraoperative bleeding during cesarean delivery or uterine rupture, a thorough evaluation of potential sources of bleeding is crucial.[77]

  • This includes assessing bleeding from the placental bed, uterine extensions, hematomas, and inferior epigastric vessels within the rectus muscles.

  • Repairing deep uterine extensions involves identifying the apex of the extension and repairing it with running, locked sutures from the apex towards the hysterotomy.

In cases of uterine rupture with a prior hysterotomy scar, laparotomy and surgical repair are necessary.[77]

  • The surgical approach depends on the site and extent of the uterine rupture, the patient’s clinical status, and desire for future fertility. Uterine rupture along a prior cesarean scar may be revised along the edges of the previous incision with a primary closure, although hysterectomy may be required as a life-saving measure in more complex cases with ongoing bleeding.[2]

  • The involvement of additional structures such as the bladder, ureter, uterine arteries, and broad ligament also needs to be assessed and repaired if necessary in conjunction with supportive resuscitative measures.[2]

Treatment of persistent uterine inversion

If persistent uterine inversion occurs despite initial interventions, surgical procedures via laparotomy become necessary.[2][21]

  • The Huntington procedure is typically the first choice, involving the use of Allis clamps to grasp the round ligaments and gently apply traction to reposition the fundus above the cervical os. If unsuccessful, the Haultain procedure can be attempted, which involves making a vertical posterior uterine incision to release the constriction ring and restore the fundus to its normal position.

  • Following these procedures, patients should be counseled for cesarean births in subsequent pregnancies due to the uterine scar resembling a posterior classical hysterotomy.

Ensure administration of uterotonics after correcting uterine inversion to prevent uterine atony and recurrence of inversion.[77]

  • In cases of recurrent uterine inversion, a uterine tamponade balloon may be considered.[2] If all interventions fail to resolve the inversion, hysterectomy is indicated due to the ongoing risk of severe PPH.

Consider – desmopressin

Back
ACUTE
|
primary postpartum hemorrhage: refractory to initial interventions
|
with von Willebrand disease
Consider – 

desmopressin

Treatment recommended for SOME patients in selected patient group

Desmopressin can be considered as an intervention for refractory PPH in patients with known von Willebrand disease type I. It is a synthetic analog of vasopressin and stimulates secretion of von Willebrand factor from endothelial cells, thereby improving platelet function.[142] See Von Willebrand disease.

secondary postpartum hemorrhage

1st line – uterotonic

Back
ACUTE
|
secondary postpartum hemorrhage
1st line – 

uterotonic

Secondary PPH (>24 hours and up to 12 weeks postpartum) accounts for approximately 1% to 2% of cases of PPH and management focuses on identifying and addressing the specific cause of the bleeding.[21]

Initial treatment of secondary PPH typically centers around the use of uterotonics (preferably oxytocin).[2]

Primary options

oxytocin: 10-40 units intravenously as a continuous infusion; 10 units intramuscularly

More

Secondary options

methylergonovine: 0.2 mg intramuscularly every 2-4 hours; 0.2 mg orally three to four times daily for up to 7 days

OR

carboprost tromethamine: 0.25 mg intramuscularly every 15-90 minutes, maximum 2 mg/total dose

OR

misoprostol: 600-1000 micrograms orally/sublingually/rectally as a single dose

Plus – antibiotics

Back
ACUTE
|
secondary postpartum hemorrhage
|
with endometritis
Plus – 

antibiotics

Treatment recommended for ALL patients in selected patient group

Suspect endometritis as the underlying cause of secondary PPH in patients who present with fundal tenderness and infectious signs/symptoms.[2]

  • Endometritis requires broad-spectrum antibiotic coverage, with a combination of gentamicin plus clindamycin commonly used.[2][143][144]

Treat until there is clinical improvement (e.g., no fundal tenderness) and the patient is afebrile for 24-48 hours.

Primary options

gentamicin: 5 mg/kg intravenously once daily; 1.5 mg/kg intravenously every 8 hours

and

clindamycin: 900 mg intravenously every 8 hours

Plus – treatment of underlying cause

Back
ACUTE
|
secondary postpartum hemorrhage
|
with noninfectious underlying cause
Plus – 

treatment of underlying cause

Treatment recommended for ALL patients in selected patient group

Tailor management to the individual patient, targeting the suspected cause of the hemorrhage to achieve effective control and prevent further complications.[2] This may involve interventions aimed at:[21]

  • Removing retained products of conception. Perform ultrasound evaluation to assess for retained placental tissue. Uterine curettage may be indicated for the removal of retained placental tissue, and should be performed under ultrasound guidance to prevent perforation.[2]

  • Addressing vascular abnormalities or managing coagulation disorders. Rarely, patients with undiagnosed coagulopathy disorders such as von Willebrand disease may present with delayed PPH.[2]

  • Resolving subinvolution of the placental site (a delay or impairment in the normal process of the uterus returning to its prepregnancy state after childbirth). This requires prompt diagnosis and management to prevent excessive bleeding and other potential complications. This may involve manual removal of retained placental tissue, administration of antibiotics for infection, or other interventions as deemed necessary by healthcare providers. Close monitoring and follow-up are important to ensure proper involution of the uterus and to prevent further complications.[2]

ONGOING

postpartum hemorrhage resolved

1st line – iron supplementation

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ONGOING
|
postpartum hemorrhage resolved
1st line – 

iron supplementation

Patients with significant postpartum anemia as a result of PPH may require outpatient treatment with intravenous or oral iron to replete iron stores, with a repeat assessment of their blood count postpartum. In some cases where the woman is symptomatic, a transfusion of red blood cells may be offered.[2]

See Iron-deficiency anemia.

Consider – red blood cell transfusion

Back
ONGOING
|
postpartum hemorrhage resolved
Consider – 

red blood cell transfusion

Treatment recommended for SOME patients in selected patient group

If a woman has severe and symptomatic postpartum anemia as a result of PPH, a transfusion of red blood cells may be offered.[2]

Consider – venous thromboembolism (VTE) prophylaxis

Back
ONGOING
|
postpartum hemorrhage resolved
Consider – 

venous thromboembolism (VTE) prophylaxis

Treatment recommended for SOME patients in selected patient group

For patients who received massive transfusion of blood products as part of PPH management, VTE prophylaxis is recommended because of the increased risk for VTE.[68]

See Venous thromboembolism (VTE) prophylaxis.

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