Refractory postpartum uterine hemorrhage

Refractory Postpartum Uterine Hemorrhage

Refractory postpartum uterine hemorrhage (PPH) is an obstetric emergency in which bleeding is not controlled by conventional management. It is considered a major cause of maternal morbidity and mortality in the United States and globally. PPH occurs in approximately 1 in every 1000 deliveries, with an estimated incidence of 1-2% among all births. It is more common in preterm and early-term deliveries. Approximately 70-80% of cases are due to atony, while the remainder are the result of other causes such as retained placenta, trauma, or retained products of conception To address this challenging problem, an increasing number of advanced therapy options are being included in the management armamentarium.

Causes of Refractory Postpartum Uterine Hemorrhage

The causes of refractory PPH are typically grouped into primary and secondary categories.

  • Primary causes include unpredictable or unrecognized uterine abnormalities, such as an abnormally contractile myometrium or an abnormally adherent placenta.
  • Secondary causes are the most common and are usually the result of inadequate management of the primary cause.

Management of Refractory Postpartum Uterine Hemorrhage

The management of refractory PPH requires an appropriate, coordinated patient-specific approach.

  • First line medical management typically includes emeletive blood transfusion, uterotonic agents such as oxytocin, ergot alkaloid, , and adjunct therapies such as recombinant factor VIIa and tranexamic acid.
  • Second line intervention typically requires advanced therapies such as B-lynch sutures, uterine artery embolization, balloon tamponade, laparoscopy and hysteroscopy.
  • Finally, definitive uterine surgery is reserved for cases in which the other therapies were unsuccessful.

In addition to the potential medical and procedural complications, there are also psychological considerations related to PPH that should be evaluated and treated. Postpartum hemorrhage is a threatening situation for women and can lead to feelings of terror, loss, grief, and guilt. Health care providers should be aware of these psychological aspects and offer appropriate management support.


Refractory PPH is a life-threatening condition that requires an immediate, coordinated, and patient-specific approach in order to prevent significant maternal morbidity and mortality. The management of these cases is complex and requires skilled and experienced clinicians to optimize the outcomes. The timely use of an appropriate management strategy and the use of advanced therapies when necessary are essential for an optimal patient outcome.