ICU · obstetric
Acute Postpartum Haemorrhage — Comprehensive ICU Management
Also known as Postpartum haemorrhage · PPH · Obstetric haemorrhage · Uterine atony · Placenta accreta · Obstetric DIC · Bakri balloon · B-Lynch suture
Acute postpartum haemorrhage (PPH) — ACOG defines maternal haemorrhage as cumulative blood loss of 1000 mL or more, or blood loss with signs or symptoms of hypovolaemia, within 24 hours of birth; it remains the leading cause of maternal mortality worldwide. Identify the cause with the 4 Ts: Tone (uterine atony — the leading cause), Trauma, Tissue (retained placenta, placenta accreta spectrum), Thrombin (coagulopathy or DIC). Management: call for help and use a standardised bundle (E-MOTIVE), resuscitate with balanced 1:1:1 transfusion (PROPPR), give tranexamic acid 1 g IV as soon as possible and within 3 hours (WOMAN trial: death from bleeding 1.5 percent vs 1.9 percent, RR 0.81), then the uterotonic ladder — low-dose oxytocin first-line (ED90 0.35 IU at elective caesarean), second-line methylergonovine or carboprost 250 mcg IM, misoprostol 600 to 1000 mcg — then uterine balloon tamponade (pooled success about 86 percent) and uterine-sparing surgery before hysterectomy. A fibrinogen at or under 2 g/L predicts severe PPH. Complications: Sheehan syndrome, amniotic fluid embolism (case fatality 19 percent).
Checked against its sources on 2 Sept 2026
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Red flags
- Cumulative blood loss of 1000 mL or more, or any blood loss with signs of hypovolaemia, is an obstetric emergency — activate the massive transfusion response and call senior obstetric, anaesthetic and haematology help
- Uterine atony is the leading cause of PPH — palpate the uterus first: a soft boggy fundus means atony; give uterotonics before hunting for other causes
- Tranexamic acid 1 g IV reduces death from bleeding in PPH (WOMAN trial) — give as soon as possible after onset, within 3 hours of birth
- Carboprost should be used cautiously in asthma — large database data show it is prescribed less often and flagged for status asthmaticus risk in asthmatic women
- Ergot alkaloids (ergometrine or methylergonovine) can precipitate acute severe pulmonary and systemic hypertension — avoid in pre-eclampsia, hypertension and cardiac disease
- Fibrinogen at or under 2 g/L during active PPH marks severe-PPH risk — in the derivation cohort the positive predictive value was 100 percent
- Placenta accreta spectrum needs a multidisciplinary planned delivery — never forcibly avulse an adherent placenta
Meet the patient
A 34-year-old woman reaches your ICU forty minutes after an emergency caesarean for fetal distress. The estimated loss is 2.8 litres, the uterus is still boggy despite an oxytocin infusion, her BP is 78 over 42, her lactate is 5.1, and she has asthma and pre-eclampsia.[1]
Two questions. Before reaching for a single uterotonic, decide what is the cause — palpate the uterus first (a soft boggy fundus is atony until proven otherwise — the leading cause of PPH) and what comorbidity forbids (asthma makes carboprost a drug to use cautiously; hypertension and cardiac disease make the ergot alkaloids the wrong choice).[8][14][15]
References19ShowHide
- [1]Committee on Practice Bulletins-Obstetrics Practice Bulletin No. 183: Postpartum Hemorrhage Obstet Gynecol, 2017.PMID 28937571
- [2]Giouleka S, Tsakiridis I, Kalogiannidis I, et al. Postpartum Hemorrhage: A Comprehensive Review of Guidelines Obstet Gynecol Surv, 2022.PMID 36345105
- [3]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
- [4]Roberts I, Shakur H, Afolabi A, et al. The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial Lancet, 2011.PMID 21439633
- [5]Gallos I, Devall A, Martin J, et al. Randomized Trial of Early Detection and Treatment of Postpartum Hemorrhage N Engl J Med, 2023.PMID 37158447
- [6]Charbit R, 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
- [7]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
- [8]Balki M, Wong CA Refractory uterine atony: still a problem after all these years Int J Obstet Anesth, 2021.PMID 34391025
- [9]Onwochei DN, Desai N, Tsen LC Uterotonics update Best Pract Res Clin Anaesthesiol, 2024.PMID 39764811
- [10]Carvalho JC, Balki M, Kingdom J, et al. Oxytocin requirements at elective cesarean delivery: a dose-finding study Obstet Gynecol, 2004.PMID 15516392
- [11]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
- [12]Toppozada M, El-Bossaty M, El-Rahman HA, et al. Control of intractable atonic postpartum hemorrhage by 15-methyl prostaglandin F2 alpha Obstet Gynecol, 1981.PMID 6973730
- [13]Cole NM, Kim JJ, Lumbreras-Marquez MI, et al. Second-Line Uterotonics for Uterine Atony: A Randomized Controlled Trial Obstet Gynecol, 2024.PMID 39326051
- [14]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
- [15]Spitzer Y, Weiner MM, Beilin Y Cesarean Delivery in a Parturient with Left Ventricular Noncompaction Complicated by Acute Pulmonary Hypertension After Methylergonovine Administration for Postpartum Hemorrhage A A Case Rep, 2015.PMID 26050249
- [16]Mousa HA, Alfirevic Z Treatment for primary postpartum haemorrhage Cochrane Database Syst Rev, 2007.PMID 17253486
- [17]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
- [18]Fitzpatrick KE, Tuffnell D, Kurinczuk JJ, et al. Incidence, risk factors, management and outcomes of amniotic-fluid embolism: a population-based cohort and nested case-control study BJOG, 2016.PMID 25683758
- [19]Karaca Z, Laway BA, Dokmetas HS, et al. Sheehan syndrome Nat Rev Dis Primers, 2016.PMID 28004764