Prevention and Management of Postpartum Haemorrhage

Definitions

• Primary PPH: blood loss from the genital tract of 500ml or more within 24 hours of delivery
• Minor PPH: 500-1000ml
• Major PPH: >1000ml (moderate 1000-2000ml, severe >2000ml)
• Massive PPH: >2000ml or rate of loss >150ml/min or >50% blood volume lost
• Secondary PPH: abnormal bleeding from the genital tract between 24 hours and 12 weeks postpartum

Risk Factors

• Antenatal: previous PPH, multiple pregnancy, polyhydramnios, high parity, fibroids, placenta praevia, placenta accreta spectrum, BMI >35, maternal age >40, pre-eclampsia, anaemia
• Intrapartum: prolonged labour, augmented labour, precipitate labour, operative vaginal delivery, caesarean section, general anaesthesia, episiotomy/perineal tears, chorioamnionitis, retained placenta

Four T's of PPH

1. Tone (70%): uterine atony — most common cause
2. Trauma (20%): genital tract lacerations, uterine rupture, uterine inversion
3. Tissue (10%): retained placenta or placental fragments, placenta accreta
4. Thrombin (<1%): coagulopathy — DIC, pre-existing bleeding disorder, anticoagulant therapy

Prevention

• Active management of the third stage reduces PPH risk by 60%
• Components: prophylactic uterotonic, controlled cord traction, early cord clamping (if PPH risk high)
• First-line prophylactic uterotonic: oxytocin 10 IU IM or 5 IU slow IV
• For caesarean section: oxytocin 5 IU slow IV
• Higher-risk women: consider carbetocin 100mcg IV or oxytocin + ergometrine (Syntometrine)

Stepwise Management Algorithm

1. Call for help — multidisciplinary team, senior obstetrician, anaesthetist, haematologist
2. ABC assessment — two large-bore IV cannulae (14G), bloods (FBC, coag, crossmatch 4 units), fluid resuscitation
3. Identify and treat cause (4 T's)
4. Bimanual uterine compression (rubbing up the fundus)
5. Pharmacological management (see below)
6. Intrauterine balloon tamponade (Bakri balloon)
7. Surgical interventions if pharmacological measures fail
8. Interventional radiology (uterine artery embolisation) if available
9. Hysterectomy as last resort

Pharmacological Interventions

| Drug | Dose | Route | Notes | |------|------|-------|-------| | Oxytocin | 5 IU slow IV or 40 IU in 500ml infusion | IV | First-line | | Ergometrine | 500mcg | IM or slow IV | Contraindicated in hypertension, pre-eclampsia | | Carboprost (Hemabate) | 250mcg, repeat every 15min (max 8 doses) | IM (intramyometrial) | Contraindicated in asthma | | Misoprostol | 800-1000mcg | Sublingual/rectal | Useful when IV access unavailable | | Tranexamic acid | 1g IV over 10min | IV | Give within 3 hours of onset (WOMAN trial) |

Surgical Interventions

• B-Lynch suture (uterine compression suture)
• Internal iliac artery ligation
• Uterine artery ligation
• Selective arterial embolisation (interventional radiology)
• Subtotal or total hysterectomy — definitive treatment when all else fails

Massive Transfusion

• Activate massive transfusion protocol early
• Target ratio: 1 unit FFP per 1 unit packed red cells
• Consider cryoprecipitate if fibrinogen <2g/L
• Point-of-care coagulation testing (TEG/ROTEM) guides targeted replacement
• Cell salvage may be used in obstetric haemorrhage

Important Facts for MRCOG

• Uterine atony is the most common cause of primary PPH (70%)
• Active management of the third stage is recommended for all women
• Tranexamic acid should be given within 3 hours (WOMAN trial evidence)
• Carboprost is contraindicated in asthma
• Ergometrine is contraindicated in hypertension/pre-eclampsia
• B-Lynch suture is a fertility-preserving surgical option
• PPH is the leading direct cause of maternal death globally

Source: RCOG Green-top Guideline No. 52 (2016 (updated 2022))

Read the original on rcog.org.uk

Clinically reviewed by NHS obstetricians and gynaecologists · Source last updated 2016 (updated 2022)

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