Postpartum haemorrhage — viva (4 Ts, uterotonics, WOMAN trial)

Opening stem

"She has lost 1.2 litres after delivery and the uterus is boggy. Manage."

Q1: Definition and 4 Ts (2 min)

• Primary PPH ≥500 mL/24 h (vaginal) or ≥1000 mL after CS; clinical shock matters more than exact mL.
• Tone, Trauma, Tissue, Thrombin — atony is ~70%.
• Risk factors: multiparity, prolonged labour, multiple pregnancy, polyhydramnios, previous PPH, chorioamnionitis, APH, instrumental delivery.

Q2: Resuscitation and medical therapy (3 min)

• Call for help, ABC, 2× large-bore IV, bloods/crossmatch, MOH protocol, bimanual compression, catheterise bladder.
• Uterotonics:
  • Oxytocin 5 IU slow IV + infusion
  • Ergometrine 500 micrograms IM — avoid in hypertension/PET
  • Carboprost 250 micrograms IM q15 min (max 8) — avoid in asthma
  • Misoprostol 800 micrograms SL/PR
• TXA 1 g IV within 3 h (WOMAN); repeat 1 g if needed.^[1]

Q3: Escalation (2 min)

• Balloon tamponade → B-Lynch → vessel ligation/embolisation → hysterectomy.
• Always reassess tears and retained placenta; correct coagulopathy and hypothermia/acidosis/hypocalcaemia.

Q4: Prevention and secondary PPH (1 min)

• Active management of third stage; calibrated drapes/early warning (E-MOTIVE).^[2]
• Secondary PPH: infection + retained products — antibiotics, ultrasound, evacuation if needed.

Key phrases examiners want

• "Four T's — tone first if boggy."
• "Ergometrine not in pre-eclampsia; carboprost not in asthma."
• "Tranexamic acid one gram within three hours."
• "Hysterectomy is life-saving, not a failure of nerve."

References2ShowHide

1. [1]WOMAN Trial Collaborators. Early tranexamic acid in PPH. Lancet, 2017.PMID 28456509
2. [2]Gallos I, et al. Randomized Trial of Early Detection and Treatment of Postpartum Hemorrhage. N Engl J Med, 2023.PMID 37158447