Management of Postpartum Hemorrhage

Initial Management

• The Association of Anaesthetists recommends administering intravenous tranexamic acid (TXA) 1 g over 10 minutes as the immediate next step in postpartum hemorrhage management, as it reduces bleeding-related mortality when given within 3 hours of delivery, with effectiveness declining by approximately 10% for every 15 minutes of delay 1, 2
• TXA has demonstrated reduced risk of severe postpartum hemorrhage, death from bleeding, and need for laparotomy in international trials, with a strength of evidence supporting its use as a first-line treatment 2, 3

Uterotonic Therapy

• The American College of Obstetricians and Gynecologists is not mentioned, however the 2025 Association of Anaesthetists guidelines explicitly recommend TXA as part of the first-response bundle for postpartum hemorrhage, alongside uterotonic drugs 1, 2

Monitoring and Coagulation Management

• Patients with postpartum hemorrhage are at high risk for hypofibrinogenemia, with fibrinogen levels <2 g/L occurring in 17% of cases with blood loss exceeding 2000 mL, and early fibrinogen replacement with cryoprecipitate or fibrinogen concentrate should be considered if levels <2-3 g/L with ongoing bleeding 2, 3
• Platelet transfusion is rarely needed unless postpartum hemorrhage exceeds 5000 mL or platelet count <75 × 10⁹/L 2, 3

Interventional Radiology

• The American College of Radiology guidelines indicate that imaging and embolization should be considered after conventional medical treatment has been unsuccessful, and uterine artery embolization may be considered in hemodynamically stable patients who have failed medical management and non-surgical interventions 4, 5

Management of Postpartum Hemorrhage Unresponsive to Initial Measures

Surgical Hierarchy

• Embolization is particularly useful when there is no single identifiable source of bleeding at examination, as indicated by the American College of Radiology 6
• Uterine artery ligation may be considered but has decreased efficacy due to collateral circulation and can be technically difficult, according to the American College of Obstetricians and Gynecologists 6
• Hysterectomy is reserved as the last resort when all other measures have failed, as recommended by the American College of Obstetricians and Gynecologists 6

Diagnostic Considerations

• Imaging with CT or CTA may be helpful in hemodynamically stable patients to localize bleeding source before embolization, as suggested by the American College of Radiology 7, 8