Obstetric Haemorrhage & DIC

Also known as Postpartum haemorrhage · PPH · Major obstetric haemorrhage · Uterine atony · Tranexamic acid · Massive transfusion protocol · Pregnancy DIC

Major obstetric haemorrhage is the leading cause of maternal mortality globally. The causes sort into the 4 Ts: Tone (uterine atony — the commonest, about 70 percent), Trauma (lacerations, rupture), Tissue (retained products, accreta spectrum), Thrombin (coagulopathy or DIC). Management pairs resuscitation with cause control: activate the massive transfusion protocol (balanced ratios borrowed from PROPPR; cryoprecipitate for fibrinogen — at or below 2 g/L is the alarm in pregnancy), give tranexamic acid 1 g IV early — within 3 hours (WOMAN trial), climb the uterotonic ladder (oxytocin, ergometrine, carboprost, misoprostol) and the surgical escalation (Bakri balloon, B-Lynch suture, embolisation, hysterectomy).

high24 referencesUpdated 26 July 202637 min readSource-verified · Sept 2026

Checked against its sources on 1 Sept 2026

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8 MCQs

The one-line answer

Major obstetric haemorrhage is the leading global killer of mothers, and almost every case folds into the 4 Ts — Tone (atony, the commonest cause and the first thing you palpate), Trauma (laceration or rupture), Tissue (retained placenta or accreta), and Thrombin (coagulopathy or DIC). Resuscitate in parallel with cause control: call for help and activate the massive transfusion protocol, give tranexamic acid 1 g IV as soon as possible — within 3 hours (WOMAN trial), run the balanced blood-product resuscitation used in trauma (the PROPPR 1:1:1 plasma:platelet:red-cell ratio) with fibrinogen support, climb the atony ladder — oxytocin, then balloon tamponade, then compression sutures, then arterial ligation or embolisation, then hysterectomy — and for DIC treat the trigger and replace what is consumed.^[2]^[4]^[5]^[7]

Meet the patient

She is 34, three hours after a vaginal delivery of her third baby following a prolonged second stage, and the midwife has rung you because the blood will not stop. The drapes are soaked, the floor pad is filling, her fundus is soft and boggy, and she is pale, restless, and cool. Heart rate 128, blood pressure 84 over 48, oxygen saturations 96 percent on room air, and a single 18-gauge cannula is all that is running. She has already had oxytocin and is still bleeding.^[1]

Two questions decide her next hour, and they decide every obstetric bleed: what is bleeding (palpate the fundus, then inspect — the 4 Ts) and is the clot holding (the fibrinogen, the platelets, the ISTH score). Hold those two questions and the cascade below slots into place.^[1]

References24Show

[1]Giouleka S, Tsakiridis I, Kalogiannidis I, et al. Postpartum Hemorrhage: A Comprehensive Review of Guidelines Obstet Gynecol Surv, 2022.PMID 36345105
[2]WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial Lancet, 2017.PMID 28456509
[3]Williams CR, Huffstetler HE, Nyamtema AS, et al. Transfusion of blood and blood products for the management of postpartum haemorrhage Cochrane Database Syst Rev, 2025.PMID 39911088
[4]Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial JAMA, 2015.PMID 25647203
[5]Balki M, Wong CA Refractory uterine atony: still a problem after all these years Int J Obstet Anesth, 2021.PMID 34391025
[6]Pineles BL, Sibai BM, Sentilhes L Is conservative management of placenta accreta spectrum disorders practical in the United States? Am J Obstet Gynecol MFM, 2023.PMID 36113717
[7]Wolfovitz A, Brenner B, Solt I Postpartum Disseminated Intravascular Coagulation: A Comprehensive Review of Pathophysiology, Diagnosis, Management, and Prevention Semin Thromb Hemost, 2026.PMID 40680793
[8]Charbit B, Mandelbrot L, Samain E, et al. The decrease of fibrinogen is an early predictor of the severity of postpartum hemorrhage J Thromb Haemost, 2007.PMID 17087729
[9]Mousa HA, Blum J, Abou El Senoun G, et al. Treatment for primary postpartum haemorrhage Cochrane Database Syst Rev, 2014.PMID 24523225
[10]Widmer M, Piaggio G, Nguyen TMH, et al. Heat-Stable Carbetocin versus Oxytocin to Prevent Hemorrhage after Vaginal Birth N Engl J Med, 2018.PMID 29949473
[11]Committee on Practice Bulletins-Obstetrics Practice Bulletin No. 183: Postpartum Hemorrhage Obstet Gynecol, 2017.PMID 28937571
[12]Alghanem H, Liu NC, Gupta A, et al. Ratios of calcium to citrate administration in blood transfusion for traumatic hemorrhage: A retrospective cohort study Transfusion, 2024.PMID 39351914
[13]Butwick AJ, Goodnough LT Transfusion and coagulation management in major obstetric hemorrhage Curr Opin Anaesthesiol, 2015.PMID 25812005
[14]Sultan P, Seligman K, Carvalho B Amniotic fluid embolism: update and review Curr Opin Anaesthesiol, 2016.PMID 27153475
[15]Adelborg K, Larsen JB, Hvas AM Disseminated intravascular coagulation: epidemiology, biomarkers, and management Br J Haematol, 2021.PMID 33555051
[16]Tang J, Lin Y, Mai H, et al. Meta-analysis of reference values of haemostatic markers during pregnancy and childbirth Taiwan J Obstet Gynecol, 2019.PMID 30638475
[17]Giancarelli A, Birrer KL, Alban RF, et al. Hypocalcemia in trauma patients receiving massive transfusion J Surg Res, 2016.PMID 27083965
[18]Makino Y, Miyake K, Okada A, et al. Predictive accuracy of the shock index for severe postpartum hemorrhage in high-income countries: A systematic review and meta-analysis J Obstet Gynaecol Res, 2022.PMID 35661488
[19]Njogu R, Tappis H, Orji BC, et al. From guesstimates to game changers: Introducing objective measurement of blood loss for timely postpartum hemorrhage detection in Nigeria, Zambia, and Kenya Int J Gynaecol Obstet, 2026.PMID 42260002
[20]Zhang Y, Yan J, Han Q, et al. Emergency obstetric hysterectomy for life-threatening postpartum hemorrhage: A 12-year review Medicine (Baltimore), 2017.PMID 29137030
[21]Carvalho JC, Balki M, Kingdom J, et al. Oxytocin requirements at elective cesarean delivery: a dose-finding study Obstet Gynecol, 2004.PMID 15516392
[22]Booker WA, Siddiq Z, Huang Y, et al. Use of Antihypertensive Medications and Uterotonics During Delivery Hospitalizations in Women With Asthma Obstet Gynecol, 2018.PMID 29889742
[23]Suarez S, Conde-Agudelo A, Borovac-Pinheiro A, et al. Uterine balloon tamponade for the treatment of postpartum hemorrhage: a systematic review and meta-analysis Am J Obstet Gynecol, 2020.PMID 31917139
[24]Rubin RN, Colman RW Disseminated intravascular coagulation. Approach to treatment Drugs, 1992.PMID 1282866