For Physicians. By Physicians.™
For Physicians. By Physicians.™
ACOG defines PPH as cumulative blood loss ≥ 1,000 mL or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after the birth process (including intrapartum) regardless of route of delivery. Unfortunately, postpartum hemorrhage (PPH) is still a leading cause of maternal mortality worldwide. Following this summary, you can find excellent professional resources at the California Maternal Quality Care Collaborative (CMQCC) and ACOG Safe Motherhood Initiative sites.
In the setting of PPH, consider the 4 ‘T’s
Uterine atony is the single most common cause of PPH (70-80%)
DRUG |
DOSE |
CONTRAINDICATIONS |
|---|---|---|
Oxytocin (Pitocin) |
10-40 units per 500-1000ml solution continuous infusionOR10 units IM |
Hypersensitivity to this medication |
Methyl-ergonovine (Methergine) |
0.2 mg IM every 2 to 4 hours |
Avoid: Hypertension, Preeclampsia, Cardiovascular Disease |
Prostaglandin F2 Alpha (Hemabate) |
250 micrograms IM (may repeat in q15 – 90 minutes, maximum 8 doses)ORIntramyometrial: 250 micrograms |
Avoid: AsthmaCaution: Hypertension, Active Hepatic, Pulmonary, Cardiac Disease |
Misoprostol (Cytotec) |
600 – 1000 micrograms PR, PO or SL |
Hypersensitivity to this medication |
NOTE: Contraindications include hypersensitivity to the specific medication
Although the generalizability of the WOMAN trial and the degree of effect in the United States is uncertain, given the mortality reduction findings, tranexamic acid should be considered in the setting of obstetric hemorrhage when initial medical therapy fails. (Level B evidence)
Based on evidence review, WHO also supports the use of tranexamic acid with postpartum hemorrhage
Early use of intravenous tranexamic acid (within 3 hours of birth) in addition to standard care is recommended for women with clinically diagnosed postpartum haemorrhage following vaginal birth or caesarean section (Strong recommendation, moderate quality of evidence)
Administration of TXA should be considered as part of the standard PPH treatment package and be administered as soon as possible after onset of bleeding and within 3 hours of birth
The reference point for the start of the 3-hour window for starting TXA administration is time of birth
If time of birth is unknown, the best estimate of time of birth should be used as the reference point
TXA should be used in all cases of PPH, regardless of whether the bleeding is due to genital tract trauma or other causes
because of the possible additive effect of the increased risk of thrombosis from COVID-19 infection and the hypercoagulative state of pregnancy, it may be prudent to consider this increased likelihood of clotting before administering TXA for postpartum hemorrhage
The key to managing PPH is identifying the severity of the situation early and quantifying estimated blood loss (EBL). A second large bore (16 gauge or larger) should be placed and Ringers Lactate used to replace blood loss at 2:1 while, simultaneously as the team is notified, medications are administered to the patient and massive transfusion protocol is initiated. Initiate fundal massage and place a Foley catheter.
Note: The FDA, the World Health Organization, and other professional bodies have released an alert following drug-error deaths related to TXA | TXA use during cesarean delivery has been associated with fatal accidental intrathecal administration because the ampoules of local anesthetic and tranexamic acid are similar in appearance | TXA should not be stored on or near an anesthetic trolley
ACOG Safe Motherhood Initiative – Obstetric Hemorrhage
FIGO recommendations on the management of postpartum hemorrhage 2022
AWHONN video: Quantification of Blood Loss
ACOG Committee Opinion 794: Quantitative Blood Loss in Obstetric Hemorrhage
ACOG Practice Bulletin 183: Postpartum Hemorrhage
California Maternal Quality Care Collaborative (CMQCC): OB Hemorrhage ToolkitV3.0
WHO recommendation on tranexamic acid for the treatment of postpartum haemorrhage
ACOG COVID-19 FAQs for Obstetrical Care
Tranexamic acid at cesarean delivery: drug‐error deaths
Uterine-sparing surgical procedures to control postpartum hemorrhage
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